Hiccups: A Medical Conundrum

Hiccups are a common annoyance. Most of the time they are a benign, self-limited condition that resolve on their own. Some of the time, however, they can become a persistent, chronic problem and, in these cases, might indicate a more serious underlying pathology. There are many theories about the pathophysiology of persistent hiccups – from problems with the central and peripheral nervous systems to post-operative diaphragmatic irritation to metabolic derangements. Psychogenic and idiopathic hiccups are other alternatives. There are also several theories about the pathophysiology of self-limited hiccups, but none are well-established. These include gastric distention, alcohol ingestion, smoking, ingestion of particular foods, ingestion of foods at the extremes of temperature, exposure of the body to a rapid temperature change, stress, and heightened emotions.

And the cure? Well, as with so many things in medicine, there is none. There are several laymen’s approaches to arresting hiccups that are often used by patients before seeking medical care, some of which rely on pharyngeal stimulation or interference with the normal respiratory cycle. These include: sipping ice water, gargling with water, biting a lemon, drinking water upside down, drinking water from the far side of a glass, a teaspoon of vinegar, a teaspoon of honey, and holding one’s breath. The list goes on. A letter to the editor, Granulated Sugar as Treatment for Hiccups in Conscious Patients, published in 1971 in the New England Journal of Medicine advocated for the use of one teaspoon of white granulated sugar, swallowed “dry.”

The medical anecdotes are not well-studied, but chlorpromazine - an antipsychotic – is perhaps the most widely accepted agent for the treatment of persistent hiccups. Metaclopramide may also demonstrate some benefit.

For patients with persistent hiccups, the inconvenience – and annoyance – can become unbearable. Hiccups can ultimately lead to weight loss or difficulty sleeping and thus have an impact on people’s lives. As we continue to advance our medical knowledge and skills, perhaps we should look back at one of the simple, familiar, age-old problem which remains very much a medical mystery.

The Downsides of the Emergency Room

An article published in Smart Money on January 24, 10 Things the Emergency Room Won’t Tell You, discussed some of the downsides to emergency room care. I will tackle these claims one by one.

1. Patience will get you nowhere.

The emergency room is a busy place, and it is generally true that being clear about your symptoms is important. However, patients are generally triaged by experienced nurses and physicians who are particularly attuned to the dangers mentioned in the article – shoulder pain, for example, should not simply be disregarded because it is not chest pain. The initial workup, including an ekg to analyze the rhythm of the heart, will be performed immediately for patients who are in high-risk groups based on age, gender, and other predictive factors. This ekg will be interpreted by an experienced physician. The moral of the story? Be clear about your symptoms and alert the triage staff if there are any changes in your symptoms.

Patience will get you somewhere – it will get you, even if it takes time,  to the emergency room. Although waiting can be frustrating, if your condition was serious enough to bring you to the ER in the first place, then it is probably serious enough to warrant waiting for a complete examination by a physician. Although some conditions will not cause death or serious consequences in the first few hours, many of these conditions can progress to cause serious problems in the next 24 to 48 hours. Thus, the wait may very well be worth it. It is your health, after all, and it is better to err on the side of caution.

2. There’s a cheaper option down the street.

Urgent care centers, if they are open and are conveniently located, are certainly an alternative worth considering. They are especially good for straightforward medical problems, such as lacerations or sprains. It is true that the ER does not offer extensive information on cheaper options, other locations, or alternatives to ER care – we are there to take every sick patient who walks through our doors and to treat them as best we can. That is our primary focus. And we certainly do not want any patient to feel that we are turning them away just because their condition can be treated elsewhere. Furthermore, many ERs now have urgent care centers as part of the facility, where patients can be seen and treated by physician assistants.

3. Bring a book.

Excellent idea. I could not agree more. Waiting – to be seen, to be treated, to receive test results, or to be admitted to the hospital – are all part of the normal course of things in the hospital. Bring a book, a magazine, music, or anything else that will keep you occupied during this time.

4. Come back in the morning.

Be careful on this one. We have many patients who decide to wait until morning to come to the emergency room – and by this time they may have already been trying to “ride out” a heart attack, aortic aneurysm, or other life-threatening condition for several hours. Although the wait may be shorter in the morning hours, if there is a possibility that you have a life-threatening medical condition, you will be seen quickly at almost any hour of the day – this is the main purpose of the ER. And ultimately, experienced nurses and physicians are better equipped than you to decide how serious your condition might be – patients often underestimate the gravity of their symptoms.

5. We might make you sicker.

This is not any more true of the ER than it is of the hospital. In fact, the case used as an example in the article was of a patient who was admitted to the hospital and underwent surgery – her complications are likely not associated with her ER visit. However, it is true that hospitals are places where infections can spread. As a result, hospitals have been proactive about placing Purell dispensers outside almost every patient room in the hospital. They have also been proactive about instituting hand-washing measures with rewards and punitive measures for physicians, nurses, or other hospital staff based on overall performance. In the ER, we are especially attuned to the potential spread of infections. During the 2010 H1N1 outbreak, many ERs were so cautious that they required patients, visitors, and physicians to wear masks if there were signs or symptoms of flu (fever, chills, cough, and the list goes on).

6. To us, you’re like a lab rat…

I don’t think ER physicians would bother to do such extensive medical workup on a lab rat. And most of these tests are not invasive. The “workup” for chest pain involves blood tests, an ekg, a chest x-ray, and possibly the scheduling of an outpatient stress test if everything checks out – not an unreasonable test, I would argue, for any middle-aged person who has chest pain. Many people have chest pain, but chest pain that is serious enough to bring you to our doorstep – the ER – is taken just as seriously by us as by you. As for unnecessary testing, refer to Defensive Medicine Supersedes Quality Medicine. This is one of the problems at the heart of medicine in this country, and it is a problem that we must fight to overcome.

7. …but don’t expect us to figure out what’s wrong.

This is generally true. In the emergency room, we determine if your condition is life-threatening or if it needs urgent intervention. We decide if you need to stay in the hospital or not. We elicit certain important characteristics about what is wrong, but we cannot necessarily give you a diagnosis in the brief time period that we care for you. In the end, however – and this goes back to the title of my blog – much remains a mystery in the world of medicine and human health. Many conditions will take months or years to diagnose, and other conditions will never be given a formal diagnosis. Many conditions necessitate extensive testing or knowledge of symptoms over long periods of time – information which, for purposes of time and money, the ER is simply not equipped to obtain. But even after all the testing has been done in the outpatient setting, physicians cannot always come up with a diagnosis. This is one of the great frustrations of medicine.

8. Good luck seeing a specialist.

This is completely dependent on where you go. Furthermore, many conditions necessitate being seen by a specialist in the next few days (especially orthopedic injuries, hand injuries, and urologic issues, which are all mentioned in the article), and in these cases you will be referred to the appropriate specialist in a specific time range. Ultimately, these referrals may delay but should not compromise the quality of  your care.

9. Your doctor can get you priority access.

If you have time, alerting your physician that you are going to the ER is a good thing. However, there has been a trend since the 1960s that private physician like to rely on ER physicians more and more, and many private physicians no longer come to the ER themselves. If they are willing to, they serve as an invaluable resource – after all, they know you far better than the emergency physician who will be treating you.

10. You can choose your doctor.

There are two different points made here – one is that you can choose to see your own specialist in the ER. This is generally true if he or she is affiliated with the hospital in some way – otherwise, as in the previous point, it is difficult to get a specialist to see you in the ER if he or she does not have an established relationship with you. In fact, ER physicians often view these people as a valuable resource – even if they do not come in to see you, we make a point of calling them to obtain important medical information.

The second point is about ER certification. The article cites statistics by the Institute of Medicine that 40% of ER physicians are not board certified in emergency medicine. It is almost ironic – and a good thing – that being board-certified in EM is now the gold standard. As recently as the 1990s, it was commonplace that physicians trained in medicine and surgery ran the ER without any emergency medicine training. With the rise of ER residency programs, which began in the 1980s, we are finally catching up with the nation’s demands for board-certified ER physicians. EM residency programs continue to expand, and the requirements for full-time ER positions are becoming increasingly stringent. This is a positive trend, and I hope it continues well into the 21st century.

Emergency medicine is an invaluable part of medical care in this country, and it is important that we fill our emergency rooms with physicians who have the diagnostic skills and the proper training to recognize sick patients, to stabilize sick patients, to save lives, and to devise for all patients who walk through our doors the appropriate disposition plans that will optimize their care. Thus, in spite of some of the flaws of the ER and of the hospital in general, it comes down to risks and benefits. Do not let some of the downsides of the ER turn you away – the consequences of avoiding the health system, however unpleasant it may be, can be devastating.

Needlestick Injuries

Yesterday I cared for a nurse who was in tears – she had a needle stick exposure in the hospital and is nine weeks pregnant. Needle stick injuries are far too common in the hospital – approximately 600,000 to 800,000 needle stick and other percutaneous injuries are reported annually among US health care workers. And the true frequency is underestimated given that many health care workers do not report needle stick injuries. The operating room, of course, presents the greatest risk. Needle stick injuries place health care workers at risk for transmission of HIV, Hepatitis B, and Hepatitis C. An article in The New England Journal of Medicine, Needlestick Injuries Among Surgeons in Training, discusses the prevalence of needle sticks among surgery residents – and the all too high frequency (51%) with which they go unreported.

Here is some of the basic information. First question: if the percutaneous exposure involves a patient with Hepatitis B, HIV, or Hepatitis C, what is the seroconversion rate for the exposed person? For Hepatitis B, the seroconversion ranges from 23 to 62%, with higher rates associated with patients who are HBeAg positive, as compared to HBeAG negative. The seroconversion rate for HIV is 1:300, or 0.3% from a hollow-bore needle stick injury (Marcus, Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus, The New England Journal of Medicine 319: 1118–1123). The seroconversion rate for Hepatitis C is 1.8%.

Next question: how effective is treatment? For Hepatitis B, multiple doses of HBIG within 1 week of percutaneous exposure to HBsAg-positive blood provides 75% protection from HBV infection (Stevens et al., Perinatal hepatitis B virus transmission in the United States, JAMA 253: 1740-5). Hepatitis B vaccination (assuming you have an appropriate vaccine response, which can be determined by checking antibody titers) prior to a percutaneous needle exposure is the best way to prevent seroconversion.

For HIV, information is limited because seroconversion rates are low and studies are limited by small sample sizes. In one retrospective case-control study, after controlling for other risk factors for HIV transmission, use of zidovudine was associated with a reduction in the risk of HIV infection by 81% (95% CI of 43%-94%) (Cardo et al., A case-control study of HIV seroconversion in health care workers after percutaneous exposure, The New England Journal of Medicine 337: 1485-90). To be most effective, the treatment should be administered within an hour of possible exposure and no longer than 72 hours post-exposure.

For Hepatitis C, there is no approved prophylactic treatment available. There is no vaccine and no cure for the disease. And the virus, which can ultimately cause liver failure, is a serious one.

An excellent resource for more information, complete with references, is Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.

There are a couple of frustrations with this process. First, although these percentages are useful when looking at the data objectively, it becomes difficult when it happens to you. After all, what do percentages matter if you end up on the wrong side of the data? What if you are the 1 in 300 who will convert to HIV or the 1 in 56 who will convert to HCV? The HIV post-exposure prophylaxis (PEP) medications have quite severe side effects, including nausea, vomiting, malaise, fatigue, and – for the pregnant woman – unknown consequences on fetuses less than 12 weeks. Thus, PEP is not without its consequences.

Second, it is still possible for patients to refuse to get tested for HIV. Laws vary on a state-by-state basis regarding the requirements for patient consent. This process can be frustrating for the exposed health care worker – and with good reason. Their lives are at stake – and no matter how small the risk, it still exists. The patient’s status can help the health care worker make a better informed decision regarding PEP.

When patients come into the hospital, they should agree to consent to HIV testing if a percutaneous exposure occurs. The health care worker should not be exposed to unnecessary anguish – and uncertainty – during this process simply because a patient refuses to consent. As health care workers, we willingly put ourselves at risk every day – for transmission of TB, meningitis, influenza, H1N1, and the list goes on. When the H1N1 pandemic broke last year, there were very few health care workers who refused to come to work – we were all there for our patients. Many emergency department workers put themselves at risk for physical and verbal abuse on a daily basis. I do not know many emergency health care workers who have not been exposed to blood, vomit, viruses, and other bodily fluids during their career. As a group, health care workers must accept that there are certain risks that come with this profession. But, to ease the added burden and stress that comes along with percutaneous exposure, the laws regarding patient consent in these situations need to be re-examined.

White Coats: Can We or Should We Learn Compassion?

An article written by Dr. Sally Satel in The Wall Street Journal today, Physician, Humanize Thyself, discusses the origins of the white coat ceremony. In the 1980s, as insurance companies placed increasing pressure on physicians to minimize visit time and maximize patient volume, the medical profession at large became increasingly cynical and disgruntled. A direct result of this was the White Coat Ceremony, whereby each medical student goes up on stage to receive his or her first white coat in front of physicians, classmates, and family. Many US medical schools initiated this movement in the 1980s in an attempt to remind the emerging physicians of the importance of their role as compassionate, empathetic healers.

Does the ceremony work to encourage compassion? The short answer is no. It represents a ceremonial celebration for medical students as they move forward in their careers and enter the patient care setting for the first time. It represents a time when colleagues, faculty, and families come together to celebrate the achievements of medical students. But if we believe that, at times of frustration in the hospital, medical students will look back on this white coat ceremony and remember compassion, we are far too idealistic. I agree with Dr. Judah Goldberg, who is quoted in the article as saying, “To the extent that empathy can be taught through a ritual, a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat.” He is absolutely right: the single best way to get medical students to think about illness in a compassionate way is to put them in a hospital gown. Haines had the right idea in the film The Doctor, a story about surgeon Dr. Jack (William Hurt) who, after being diagnosed with throat cancer, is forced to view medical care from the “other” side. At the end of the film, Jack instructs all of his interns to put on gowns: they are to be patients in the hospital for the next 24 hours. Blood draws, hospital food, physical exams – they are going to experience it all, hospital life in full, from the disempowered and vulnerable viewpoint of the patient.

Still of William Hurt and Charlie Korsmo in The Doctor

In my experience, routine visits to the hospital or doctor’s office remind me what it feels like to be a patient. In general, the feeling is not good. I find that I am much more attentive to my patients’ needs after a visit like this, when my memory of my own experience remains vivid and fresh in my mind. Compassion is an important part of the physician-patient relationship. How do we achieve this? We need to listen, to comfort, and to respond to our patients’ needs. We need to care for our patients rather than their illnesses. We need to envision our patients as people and not as a laundry list of medical conditions. This last task, perhaps the most important, is also the most difficult. When we care for people day in and day out who are dressed in hospital gowns and are not feeling well, it becomes too easy for us to forget that these patients are individuals who have a full life outside of the hospital – a life about which we know very little.

A new trend in medicine is to admit students who have a degree in liberal arts. Satel mentions that some schools, like Mount Sinai School of Medicine, even admit students who have not taken some of the requisite science courses or the MCAT. Students who majored in the humanities can certainly bring a different perspective to medicine. But there is no guarantee that we are admitting students who will become compassionate physicians. Why not?

1. We cannot predict how medical students will change during their careers. It is widely acknowledged that physicians become increasingly cynical as they move forward in their careers. This cynicism is particularly evident in a field like emergency medicine, where physicians often become frustrated with caring for patients who are not linked in to our health care system. Many do not have health insurance or a primary care provider, and thus cannot follow-up appropriately. Some roam from emergency department to emergency department looking for pain medication or some inadequate, less expensive substitute for longitudinal care.

2. We cannot necessarily change someone’s inherent personality, nor can we discover it through the medical school application process. Even if we argue that certain people are inherently compassionate and that these are the people who should be trained for the job, we cannot necessarily judge which applicant is more compassionate than the next based on the limited information in a medical school application. One could argue that students on the pre-med track are inherently selfish, at least to some degree. They have many requirements to fulfill and spend much of their time in college achieving – in the classroom, in the research lab, and in their volunteer activities. Just because someone has a long list of “compassionate” activities on a résumé does not prove that they are truly compassionate. And even if they are, the argument becomes circular when we return to number 1 above.

3. The last point, and this one has more speculation involved, is that perhaps compassion is not the most important quality for a doctor. Doctors need to strike a balance between distance and intimacy. To disregard all physician-patients boundaries would likely make patients feel uncomfortable and physicians feel emotionally drained. Already, the statistics on physician well-being are not reassuring. Depression is at least as common in the medical profession as in the general population, affecting about 12% of men and 18% of women. Depression rates are higher for medical students and residents, with 15-30% screening positive for depressive symptoms. All of these numbers are likely lower than the real percentages due to under-reporting (there is significant stigma among medical professionals about psychiatric illness). After accidents, suicide is the most common cause of death among medical students. Suicide rates are higher among physicians, 28 to 40 per 100,000, than in the general population, 12.3 per 100,000 (Council on Scientific Affairs: Results and implications of the AMA-APA Physician Mortality Project, Stage II. JAMA 1987; 257:2949-2953). This is partly due to the higher success rates of suicide attempts. This data is from an eMedicine article written by Dr. Louise Andrew, entitled Physician Suicide. A perspective article by Schernhammer in The New England Journal of Medicine, Taking Their Own Lives — The High Rate of Physician Suicide, discusses some of the problems which lead to physician suicide.

Ultimately, the successful physician finds a balance between compassion and emotional distance, and he is thus able to continue his practice and live happily. But this is easier said than done, especially for physicians who are struggling through their years in residency. Perhaps a lack of compassion is our own survival mechanism.

The issue of compassion is much more complex than it seems. And I have only addressed the physician side of things – the patient side adds an entirely new dimension to the dilemma. Patients have different preferences about the degree and nature of compassion which they expect to receive from physicians. Compassion is undoubtedly an important aspect of the physician-patient relationship, but how important and in what ways is somewhat controversial. Furthermore, if a physician acts compassionately towards his patients without feeling compassionate, is this sufficient? Perhaps the act alone will suffice, if it is performed well. But to disregard compassion completely, to treat our patients as Dr. Jack initially did in the film, would be to fail as a physician and healer and to disregard a critical part of the physician’s calling.

Patient Perceptions in the Emergency Department: Physicians, Physician Assistants, Nurse Practitioners

A recent survey in the American Journal of Bioethics, Patient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis?, indicates that 80 percent of patients expect to see a physician when they come to the emergency department. Parents were more insistent about their child see a physician or resident for even a minor condition such as a sprained ankle. Patients indicated a preference for seeing a resident alone for non-urgent conditions (60%) and compared to a physician assistant (42%). Interestingly, these numbers did not vary dramatically from a resident’s preference to see a resident alone (65%) over a physician assistant (38%). Patients willingness to see a nurse practitioner (NP) was less across the board, 32% of residents, 44% of non-medical patients, and 75% of physician assistants (PAs).

One of the greatest flaws of the study is a narrow patient population – English-speaking, educated, urban. Another point of interest would be to take a larger sample size and to stratify preferences based on age. The idea of NPs and PAs practicing in the emergency department is relatively new and has increased dramatically since the initiation of new duty hour regulations for residents in the 1990s. Their visibility may increase even more if the new ACGME duty hour rules pass this year (refer to a previous post, Resident Duty Hours: Loopholes in the New Regulations). The younger population of patients in the emergency department may be more willing to see PAs and NPs than the older population.

Another problem inherent in the study is that when you ask patients their preference for medical care in the hypothetical setting, it becomes difficult for them to answer the question honestly. In some ways, the act of posing the question itself – a question which relates directly to a patient’s expectations – biases people towards answering a certain way. It makes sense to prefer to see a practitioner with the most training – with physicians, followed by senior residents, at the top of the list – regardless of the medical problem. And the question which always lingers in the back of someone’s mind, especially in the hypothetical setting, is “what if the condition is a bad sprained ankle, or maybe a little worse – a break perhaps?” If, in a real situation, the patient is less concerned about this possibility, they may be more willing to see a nurse practitioner or PA.

One interesting question is whether these perceptions are changing over time – over the course of the last 5 years. My hypothesis is that they have, and that patients are becoming more comfortable being treated by practitioners without the MD behind their name. Another interesting question is whether years of experience matter – would a patient rather see a PA who has trained for 30 years, or an attending physician who has trained for 1 year? These questions further complicate matters.

Here is the bottom line, from my perspective as a health care provider: I think it is important for patients – and for residents, PAs, and NPs – to understand that the purpose of a hierarchy in medicine is to provide more support staff, not to compromise patient care. Our primary – and most important – job, as residents, PAs, and NPs, is to recognize our limitations and to ascertain whether one of our patients needs a higher level of care. Even patients who seem healthy may be sick. The common line in emergency medicine is, “Be humble or be humbled.” We need to keep this in mind with every patient we see and have a low threshold to ask for assistance.

The expectation that patients be seen by physicians is a longstanding one, but it is beginning to change. With ED volumes as high as they are, there are simply not enough emergency physicians to see every non-urgent patient . That expectation is not only unrealistic, but it is also not necessarily beneficial to patients. PAs are often very experienced at suturing simple lacerations or taking care of ankle sprains – and are often as good or better at it than physicians, depending on their experience level.

I think as times change, as PAs and NPs become more visible in the emergency department, and as long as we continue to remember our limitations as trainees (even attending physicians ask one other for help or advice from time to time, and emergency physicians call specialist consultants down to the ED if they are concerned about a patient), we will continue to provide good patient care in a health care system with a variety of trainees, all with different levels of experience and expertise.