POTD: Valentine’s Day Special

Happy Valentine's Day to everyone enjoying the trappings of romantic love, and an early happy Singles Awareness Day to everyone else. I'd also like to point out that this coming Monday is President's Day, so we wish a belated Happy Birthday to President Lincoln (2/12) and an early Happy Birthday to President Washington (2/22). 

Today's POTD will start with a history lesson on how Valentine's Day came to be, and end with a little dip into actual medicine. 

In modern times, Valentine's Day is observed in much of the Western world as a celebration of love. C.S. Lewis (author of The Chronicles of Narnia) described four categories of "love" based on Christian and Greek philosophy: storgē, or the more widespread natural/instinctive love that arises from familiarity and empathy; philia, the love between true friends who share common values and interests, which he considered the "least natural" and "most freely chosen" form of love; eros, the passionate love directed towards an object of desire; and agape, a selfless and unconditional love which Lewis held as the pinnacle of love. Many schools of thought present other views on the etiology and expression of "love" as a concept, which I won't get further into the weeds about. Here in the USA we typically see partners having a nice evening in and/or out, and friends/classmates/coworkers exchanging tokens (i.e. cards and candy). 

But how did we get to the candy-and-dates of today's Valentine's celebration?

Let's first go back to Ancient Rome, a time period always worth thinking about for many many reasons. The Romans observed many religious feasts and festivals whose dates were speculated to have been co-opted by their successors, and in this case there was indeed a major festival celebrated mid-February. Lupercalia, which was celebrated on or around what would later be considered Feb. 15, was a rite of health and fertility in which a dog and goats were offered to the gods in a ritual sacrifice, followed by the anointing of the priests with the bloody knife, and the subsequent washing of the blood with wool and milk; then, the priests would cut thongs from the animals' skin and run naked or near-naked around the hills and through the streets of Rome, and women would come to be struck by them to promote fertility and ease pregnancy. See the painting below. Even after the Christianization of Rome in 380 CE, Lupercalia would continue to be celebrated for some time despite the persecution from various papacies. It is often said that in 496 CE, Pope Gelasius I, a noted hater of Lupercalia, decreed that there would be a new Christian observance on Feb. 14 — the Feast of Saint Valentine. However, there are no primary sources attesting to this — the "Gelasian Decree" which is often erroneously cited only mentions Cyricus & Julitta and George as martyrs to be venerated, with no word on feasts or Valentine. There is a cotemporaneous epistle written by Gelasius to Senator Andromachus justifying the former's prohibition on the Lupercalia. But I digress again.

In Christian tradition, Saint Valentine was martyred on Feb. 14 in 269 CE. The earliest surviving attestations to his story are the Martyrologium Hieronymianum, which was originally written in the 400's CE, and the Passions of Saints Marius, Martha, Audifax, and Abachu; earlier, the Chronography of 354 mentions a church built by Pope Julius I in honor of a St. Valentine, the ruins of which have been found. According to those documents, Valentinus was a priest who was brought before Emperor Claudius Gothicus for denouncing Christian persecution and the pagan gods. After admonishing the Emperor, he then healed a young girl of her blindness; as his reward, the emperor had him beheaded, along with several witnesses to the miracle who had then converted to Christianity. 7th century sources make reference to an extant feast day honoring St. Valentine, so it can be presumed that the day was established at some interim time in the 500-600 CE range. 

The next question is — how do we make the jump from a day venerating a martyr, to a day celebrating love? It's tempting to look at the debauchery of Lupercalia and say "there we go", but there's no true evidence of that linkage.

In the 14th century CE, famed author Geoffrey Chaucer (of The Canterbury Tales, and the best character in A Knight's Tale from 2001 feat. Heath Ledger) wrote the poem "The Parlement of Foules", which states "For this was on seynt Valentynes day // Whan every foul cometh there to chese his make", which is then followed by accounts of various birds-of-prey wooing an eagle while ducks and cuckoos heckle them all. Chaucer had intended his reference for a different St. Valentine who was honored in May, which made sense as that was the spring in England, and not the February winter associated with the more popular St. Valentine. Notably, the imagery of birds flocking to mate in spring was not uncommon in the poetry of that time. In the 15th century, during a bout of the plague in France, King Charles VI the Mad allegedly founded an organization called the "Court of Love" (differing from the 12th century Eleanor of Aquitaine's own "Court of Love") which called upon members to meet annually on Feb. 13 and sing love songs in front of a judging female audience. Apocryphal or not, this reflected the growing association between "birds mating in the spring", "romance", and "the St. Valentine's Day of Feb. 14", and the practice therein of men writing romantic poems to their lovers on that day. 

Banality and commercialism began to encroach upon the scene in the 18th century, when advances in printing and industrialism led to the popularization of the Valentine's Day Card — a prewritten poem with accompanying printed art, for the illiterate or uncreative young man who lacks the ability to write his own verses but has the change to spare. In 1868, Cadbury introduced the heart-shaped chocolate-filled box which has since become an iconic part of the holiday. Marketing efforts would continue over the next decades from various sources, and the De Beers blood-and-slavery diamond company would soon add the feather of "Valentine's day jewelry" to their cap. 

Now that we know about the history of Valentine's Day (and can weep for the extinction of Lupercalia, which sounds like a right splendid holiday), we can talk a little about its impact on peoples' psychological health.

After noticing an increase in suicide attempts presenting to their ED on Valentine's Day, researchers at the Department of Psychiatry at Queen Elizabeth Hospital in Birmingham in England conducted a 5-year observational study comparing para/suicide attempts on Valentine's Day and Christmas vs two control days (Feb. 7 and Aug. 15). They found that rates of suicide attempts nearly doubled on Valentine's Day relative to the controls, with a smaller but still-significant bump on Christmas as well. A disproportionate amount of the holiday suicide attempts were by adolescents. More recent surveys of the general population found that self-reported symptoms of general anxiety, depression, rumination, and social anxiety all increased in the population of those who did not receive Valentine's Day gifts. The self-identified female population experienced greater duration of symptoms than the self-identified male population. Those under 40 were more likely to experience worsening depression than those over 40. The authors speculate that societal expectations/pressures may be the root, and offer the following bits of advice for singles (and couples) combating the "Valentine's Day Blues" (paraphrased):

– Love and accept thyself. The compassion and grace that you extend to others (including patients) should be offered to yourself as well. 

– Give yourself a gift. Shopping therapy is real, and is an act of self-empowerment and self-expression. Or put the money into your retirement plan.

– Volunteering and other acts of altruism can be a healing balm on the psyche. And helps one keep their troubles in perspective.

– Engage in self-improvement. Identify reasons for your unhappiness and try to work out concrete solutions with attainable small steps.

– Stay busy and active. Idle hands are the devil's workshop.

That's all for today, and hope you all have a safe and wonderful holiday weekend!


References:

https://www.cslewis.com/four-types-of-love/

https://www.britannica.com/topic/Lupercalia

https://penelope.uchicago.edu/Thayer/E/Journals/CP/26/1/Lupercalia*.html

https://www.tertullian.org/decretum_eng.htm

https://www.roger-pearse.com/weblog/2022/02/17/the-earliest-mentions-of-st-valentine/

https://www.roger-pearse.com/weblog/2019/07/15/valentine-of-rome-bhl-8465-extracts-from-the-passiones-of-marius-martha-audifax-and-abacuc-bhl-5543/

Oruch, Jack B. "St. Valentine, Chaucer, and Spring in February". Speculum, Vol. 56, No. 3 (Jul., 1981), pp. 534-565.

https://www.ox.ac.uk/news/arts-blog/love-lessons-medieval-literature

https://pmc.ncbi.nlm.nih.gov/articles/PMC1662519/pdf/bmj00171-0029.pdf

https://journalofscientificexploration.org/index.php/jse/article/view/2445


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POTD: LUCAS Tips & Myths

Happy Thursday (it’s still Thursday on the west coast, that counts). Today I'll be talking a little about the Lund University Cardiopulmonary Assist System, or LUCAS.

The LUCAS is a device that provides mechanical chest compressions, which is used as an alternative to a human compressor. The impetus for the development of this device came when a Norwegian paramedic named Willy Vistung noted that he and his colleagues had difficulties performing high-quality manual compressions while in a speeding ambulance and while transitioning the stretcher. Cardiothoracic surgeon Stig Steen continued development of a mechanical chest compression device after Vistung's passing, with prototype trials starting in Sweden's Lund University in 2000. The first generation of the LUCAS device (which was pneumatic rather than battery-powered like today's LUCAS) entered the market in 2003 in Sweden; the current model of LUCAS 3 has been on the market since 2016. By that time, 45% of all EMS services in the USA had protocols for using mechanical compression devices. 

We know that high-quality CPR is the essential component influencing survival in cardiac arrest, and the AHA's five components of high-quality CPR are: minimizing interruptions, maintaining adequate rate, maintaining adequate depth, allowing adequate chest recoil, and ventilating appropriately. In theory, use of a mechanical device such as LUCAS would help with the parameters of rate, depth, and recoil. In the hospital, there are also qualitative benefits in clearing the space at bedside that compressors would occupy, and freeing staff to perform other tasks in the resuscitation (or continue care of other critical patients). The increased quality of compressions seems to be supported by studies involving simulated transport of patients in cardiac arrest, with improvements in rate and depth compared to manual compression. However, does this actually lead to better patient outcomes? 

Multiple studies on out-of-hospital cardiac arrest have failed to show that mechanical chest compressions confer any benefit or harm to ROSC or survival. Multiple meta-analyses pooling multiple RCTs, prospective cohort studies, and retrospective studies have added to the growing body of evidence that the general population receives no change in overall outcome whether they have manual or mechanical compressions. As such the 2015 European Resuscitation Council Guidelines for Resuscitation do not recommend routine use of mechanical compression devices such as the LUCAS, but do suggest that their use is reasonable in situations where sustained high-quality manual chest compressions are impractical (such as prolonged resuscitations, transport) or compromise provider safety. The ERC and AHA both speculate that potential benefits of improved chest compression fraction with mechanical compressions may be compromised by delays/interruptions in compression incurred during the transition from manual to mechanical compressions, and recommend that additional training such as simulations/drills be offered by institutions incorporating mechanical compression devices. 

Knowing that there's 1) no harm, and 2) potential benefits both quantitatively and qualitatively, I think we should try to maximize good use of LUCAS whenever feasible. For those of you who haven't yet seen or used a LUCAS device, this is what it looks like:

There's a big yellow backboard which will stabilize the device and provide a backstop for the force of the piston. The backboard should be placed on the stretcher before the patient is transferred from the ambulance gurney, because trying to reposition/roll the patient to slide the backboard under after is not ideal. The backboard has a diagram of where it should be placed relative to the patient's chest. The two "legs" of the device should then be locked to the sides of the backboard, and the suction cup at the end of the piston should be lowered over the chest. After turning the device on, the patient's wrists should be strapped to the legs of the device (mainly to ease ergonomics in staff positioning and patient transport). If there are any problems with the device, it should beep and flash some red lights; the most common problems will be those of positioning. Getting all of this done with < 10 seconds of interruptions in chest compressions is a real challenge, and I see the utility in the "pit drills" that the ERC recommends. 

Lastly, courtesy of our sim director Dr. Lamberta, we’re aware of a page from Stryker entitled “Myth Busted! The LUCAS device does fit large patients!”. Google it for the actual document. No one will be measuring a patient's body with a ruler during an arrest, but the tech specs of the LUCAS 3 note that it can be used with a sternum height of 6.7 to 11.9 inches, and a chest width of 17.7 inches. Practically-speaking, as long as the patient's chest is not so large that the legs cannot snap in place, or that the suction cup compresses their chest while still in the "start" position, the system can be used. To paraphrase the manufacturer, a large mid-section is not an obstacle to using the LUCAS. For reference, the model in their included illustration is 5'10'' and weighs 320 lbs. 

On the other end of the spectrum, LUCAS can be applied in pediatric patients as long as they meet the minimum sternum height of 6.7 inches — that is, enough for the suction cup to be placed on their chest and still compress. The device should alarm if the patient is in fact too small for adequate compressions. My estimation is that the average preadolescent pediatric patients will be smaller or borderline. 


References:

https://www.tandfonline.com/doi/full/10.3109/17482941.2012.735675

https://www.sciencedirect.com/science/article/abs/pii/S0736467919311370

https://www.sciencedirect.com/science/article/pii/S0300957215003287

https://cpr.heart.org/-/media/CPR-Files/Resus-Science/High-Quality-CPR/CPR-Statement.pdf

https://www.sciencedirect.com/science/article/abs/pii/S0300957211001225

https://heart.bmj.com/content/98/12/908.short

https://journals.lww.com/md-journal/FullText/2019/11010/Mechanical_chest_compression_with_LUCAS_device.17.aspx

https://pmc.ncbi.nlm.nih.gov/articles/PMC8328162/

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POTD: Trauma Pan Scans & Shan Scans

Hi there, it's your friendly neighborhood admin/teaching resident and today for Trauma Tuesday we'll be talking in general about whole-body CT (or "pan-scan") for polytrauma patients, and in specific about an institutional protocol for whole-body CT that is used at the Shock Trauma Center at UMD Baltimore. For those who have ever had the pleasure of rotating at STC, this might be more-familiarly called the "Shan scan". 

The use of whole-body CT in polytrauma has rapidly increased in the two-odd decades since it first gained a foothold in trauma center EDs. Imagine a world where only 5% of "major trauma" patients (i.e. patients that would fall into the trauma level 1 and 2 categories here at Maimo based on mechanism, vitals, on-scene findings, etc.) get pan-scanned, but that was 2002. Whole-body CT as a term exists in contrast to selective CT imaging, wherein only regions of interest identified on exam, E-FAST, and CXR/PXR are put through cross-sectional imaging. Institutional protocols vary, but the most common battery of imaging includes non-contrast CT head, non-contrast CT C-spine, and contrast CT chest/abdomen/pelvis; additional limbs or phases can be added based on clinical needs. Depending on the protocol, whole-body CT may precede or follow the E-FAST and CXR/PXR.

Early research comparing WBCT to NWBCT mostly comprised retrospective or non-randomized studies, with numerous variations in institutional characteristics (distance to CT scanner, level of trauma center, etc.) as well as in protocols (such as timing of WBCT, whether done immediately after primary survey or after E-FAST and XRs). Meta-analyses of this phase found that WBCT had an association with decreased mortality, shorter ED stays, and shorter time to OR. 

2016 would bring us the first RCT comparing WBCT to standard imaging. The European REACT-2 study compared immediate WBCT vs POCUS/XR + selective CT in adult patients presenting with potential severe injuries based on initial assessment (any of RR≥30 or ≤10, HR≥120, SBP≤100, EBL≥500ml, GCS≤13, abnormal pupil exam; or concern for ≥2 long bone fractures, multiple rib fractures, flail chest, open chest, pelvic fracture, unstable vertebral fractures, cord compression; or severe mechanism such as fall from ≥3 meters, or ejection from vehicle). In the WBCT group, CT followed any life-saving interventions (such as intubation or chest tube insertion) but preceded any POCUS or XR. In the control group, selective CT followed POCUS and XR; interestingly, nearly half of patients in the control group ended up being pan-scanned. The authors found no difference in in-hospital mortality between the groups (15.9% vs 15.7%), but did find significant timing benefits to WBCT in the form of 30 min vs 37min to completion of imaging, and 50 min vs 58 min to diagnosis; but failed to find a statistically significant improvement in time to exit of trauma bay (63 min vs 72 min). Cost of workup was similar (€24,967 vs €26,995). The WBCT group had a small but statistically significant increase in radiation dosage (20.9 mSv vs 20.6 mSv). For context, our yearly radiation exposure in the US is approximately 3 mSv/year. The risk of cancer increases above 100 mSv/year exposure, and OSHA sets a limit of 50 mSv/year for workers in radiation environments (e.g. radiology techs, uranium miners, nuclear reactor personnel). 

So if you're at a level 1 trauma center like the hospitals in the REACT-2 study, and your patient is hemodynamically stable for CT, you can trust your clinical acumen and obtain CT imaging in whichever mode and timing you feel is appropriate. But don't forget about radiation — while differences in total exposure between the groups is small, an individual who receives WBCT when they might have only needed a CT head + C-spine is receiving an extra ~19 mSv, and they probably wouldn't thank you for it.

For the half of our major trauma patients who are getting a pan-scan anyway, the folks at Shock Trauma Center have their "Shan scan". This is named in honor of Dr. Kathirkamanathan Shanmuganathan (RIP), who was a Professor Diagnostic Radiology at UMD who made copious contributions to the field of trauma and emergency radiology, and was awarded the American Society of Emergency Radiology’s Gold Medal in 2014. In 2009, Dr. Shanmuganathan's group described a single-pass continuous WBCT protocol for polytrauma patients. They compared their protocol of noncontrast CT head followed by a scan from the circle of Willis through the pubic symphysis (with either monophasic or biphasic contrast injection) vs the conventional pan-scan (noncon CTH/C-spine, contrast CT C/A/P). They found that this single-pass protocol resulted in significantly decreased scan time (11.6 minutes vs 19 minutes). The time difference was attributed to decreased repositioning/management of the patient, and decreased software operation time. 


Beyond shaving down vital minutes (and reducing radiation exposure by eliminating redundant/overlapping areas), the Shan scan differs from the conventional pan-scan with the addition of CT angiography of the brain and neck. This can be useful for the screening/diagnosis of cerebrovascular occlusion (stroke) as well as blunt cerebrovascular injury. Remember that trauma can be a stroke chameleon! — we've had multiple M&M presentations over the last 1.5 years about basilar artery or MCA occlusions that presented as falls with head strike and neuro deficits. Meanwhile, BCVI (carotid or vertebral artery injury) has been shown to have an incidence of 0.5-2% across all major blunt trauma patients, rising to 9% in blunt head trauma and up to 41% in severe neck injury. The risk for subsequent stroke in patients with BCVI is 20-30%, with all its associated mortality and morbidity. Anticoagulation after BCVI is identified is effective in preventing stroke; sadly, in the past, up to a third of BCVI's were only diagnosed after the manifestation of stroke symptoms.

I didn't get further into the weeds on trauma radiology studies for single-pass continuous CT with regard to overall clinical/mortality benefit, but based on anecdotal evidence I myself  (as someone with a low risk tolerance) would have a low threshold to obtain a CTA head/neck as part of a trauma workup, especially if factors such as AMS or lack of collateral limit the history and exam.

References:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60232-4/abstract

https://link.springer.com/article/10.1186/s13049-014-0054-2

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30932-1/abstract

https://www.sciencedirect.com/science/article/abs/pii/S0735675717302152

https://journals.lww.com/jtrauma/fulltext/2001/08000/Treatment_of_Posttraumatic_Internal_Carotid.9.aspx

https://ajronline.org/doi/pdf/10.2214/AJR.07.3702

https://link.springer.com/article/10.1186/s13049-018-0559-1

https://www.sciencedirect.com/science/article/abs/pii/S0002961099002457