POTD: Pediatric Cannabis Ingestion (LLFTP #1)

Today's POTD is inspired by The Pitt, and will hopefully be the first in a short series of "Lessons Learned from the Pitt" (LLFTP). For those of you who don't know, The Pitt is a new medical drama on HBO/Max; created by R. Scott Gemmill (producer and writer for ER) and starring Noah Wyle (who also appeared in ER as medical student Carter) as the beleaguered ED chief. The eponymous "Pitt" is Pittsburgh Trauma Medical Center, a single-coverage trauma center in Pittsburgh with beautiful facilities and an allegedly shoestring budget. The season is structured as a single "shift" in the ED, with each episode covering 1 hour of events starting from 7am. The show strives for a higher level of realism and accuracy than other dramas (cough cough Grey's Anatomy), with Noah Wyle stating as well that they intend to showcase various challenges in the US healthcare system that patients and personnel struggle with/against.

Spoilers, obviously.

Episode 1 started off with a few good cases, but today I want to focus on little Tyler, who presents as a "lethargic 4-year-old" with no PMHx, no antecedent illness, no fever, no vomiting, no nuchal rigidity, no skin lesions. Dr. Melissa King also somehow notes "no focal neuro [findings]" on a patient too somnolent to follow any commands. FSBG is 85, and CBC, BMP, UA, and UDS are pending. Her senior resident, Dr. Frank Langdon, comes to the bedside to take his own H&P — specifically asking about possible ingestions, which the parents deny. His exam is brief, first checking for responsiveness and nuchal rigidity followed by auscultating Tyler's heart and lungs and glancing at the monitor. He confidently states "no signs of infection" without having looked under the patient's pajamas or into any cephalic orifices, and walks away.

10 minutes later, they return to reassess Tyler after noting that his CBC and BMP were unremarkable. On re-examination, Dr. Langdon looks in Tyler's mouth and notices remnants of a green gummy. Yep, it's from the stash of pot gummies that mom's brother gave to dad. That's why you gotta be thorough on your physical exam. After security helps defuse the apoplectic mother, Tyler is admitted for monitoring.

The growing decriminalization of marijuana has been followed by a rise in the incidence of accidental cannabis ingestion in children (over tenfold since 2017, with 3054 reported cases in 2021). While children (and especially young children < 5 years old) are notorious for trying to eat anything lying around (including batteries and sometimes cockroaches), this has not been helped by many common THC products coming in forms that are particularly attractive to children — cookies, brownies, gummies, and other confections. Cases are also increasing in severity, with a decrease in the proportion of cases discharged from the ED and an increase in cases requiring admission to the floor and requiring admission to the ICU (1 in 5 admission rate overall). 

The most common symptom of cannabis ingestion by far is CNS depression, with tachycardia, vomiting, ataxia, and agitation as distant runner-ups. The toxicity of THC is dose-dependent, and small children eating doses intended for adults will have a commensurately-higher weight-based exposure. Symptoms usually begin by 2 hours post-ingestion. Prolonged toxicity is characterized as having signs or symptoms > 6 hours post-ingestion. Severe toxicity is characterized as the presence of one or more of hemodynamic instability, seizure, myoclonic jerks, severely depressed mental status (responds to noxious stimuli only), agitation requiring sedation, respiratory failure, and/or apnea. In a 2023 Rocky Mountain Poison & Drug Safety study involving a pediatric hospital network, 80 patients were identified in a 7-year period with cannabis ingestions of known THC dose. 74% had prolonged toxicity, and 46 had severe toxicity (with predominantly neurological symptoms). A dose threshold of 1.7 mg/kg THC for severe or prolonged toxicity was proposed based on their data, with each additional 1 mg/kg trebling the risk of severe or prolonged toxicity. It should also be noted that the fraction of patients with known doses was the minor portion, and that severity was not compared between patients with known vs unknown doses of THC. No deaths were reported in this study, nor many other studies, attesting to the efficacy of supportive care. 

Cannabis products can regularly contain at least 5mg THC per unit, and over 200mg THC per package. A young child massing 15kg can easily exceed the threshold dose in a single sitting. Some states have risk-reduction laws that require packaging be simple/opaque and not brightly-colored and attractive to children, or that limit the amount of THC that may be contained in one package. 

This case teaches us three major lessons:

1. Consider THC toxicity in the lethargic child who might otherwise be afebrile, well-hydrated, and normoglycemic. 

2. Always look beneath the surface.

3. Asking about parents' access to drugs, and about specific substances, can help jog their memory.

Other little lessons from Episode 1:

• If you have trouble figuring out what language your patient speaks, open up Google Maps. I also polled some laypeople (friends and family) about what they would say if they woke up in a bright strange environment with a bunch of uniformed workers shouting at them in a foreign language, and they unanimously said they'd start shouting the name of their own language. 

• Recent marathon + malaise + recurrent cardiac arrest = hyperkalemia. Especially with signs like wide QRS and peaked T-waves. Do as Dr. Robby did and don't wait for labs before pushing Ca. 

• Cardiac pathology may present as upper abdominal pain, don't forget to order the ECG and troponin.

References:
https://pmc.ncbi.nlm.nih.gov/articles/PMC10952774/
https://publications.aap.org/pediatrics/article/151/2/e2022057761/190427/Pediatric-Edible-Cannabis-Exposures-and-Acute
https://www.sciencedirect.com/science/article/abs/pii/S0022347617309393
https://publications.aap.org/pediatrics/article/152/3/e2023061374/193757/Toxic-Tetrahydrocannabinol-THC-Dose-in-Pediatric
https://journals.lww.com/pec-online/abstract/2020/06000/intoxication_from_accidental_marijuana_ingestion.19.aspx
https://link.springer.com/article/10.1007/s13181-021-00849-0

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

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/