Welcome to Em pulse Brain research and expert opinion to the bedside. We're your hosts, Sarah Made. And Julia Mc. Welcome back to Ian impulse. Say it's summertime. So I think we should talk about something sunny like on ecological emergencies. Okay. Not super sunny, but definitely important. There are 16000000 Americans living with cancer. Who account for approximately 4000000 visits to emergency departments each year.
Patients with advanced cancer, especially older patients are particularly vulnerable to emergencies. And to improve our recognition and response to oncology emergencies, we are talking today with a friend of mine who is actually an ecological emergency physician. That is a crazy job. And to be clear, she is a physician who only sees adult cancer patients in the
emergency department. So while some of these principles apply, we're only talking about adults today, but that gives us the opportunity to do a follow up on kit. I like that. That's a great idea. So, Monica, I wanna start where most of us in the Ed initially interact with cancer, which is making that potential diagnosis. And we all know that ideally cancer is caught early with subtle signs in clinic or
screening through primary care physician. But there's been a decrease in access to primary care and not everyone gets that screening that they should, so we are off in the first line. What types of cancer are most likely to be diagnosed in Ed? I would say the most common cancers would be breast, colon and lung, and studies have shown that it's probably around the range of 20 to 50 percent of, dynasties for these specific mali are actually through the emergency department.
That's a lot. Yeah. For sure. I would not have expected that. You know, I think sometimes we struggle with our role in that diagnosis of cancer in the emergency department. Monica, what do you see as the role of the Ed physician in that initial discussion and diagnosis in the emergency department. I think that we have a very, very vital role to play and a role that maybe we had not initially thought of when we were in residency training.
A lot of times when we are thinking of cancer patients comes to the emergency department. They might be symptomatic from something. But I wanna take a step back and they and talk about just, you know, incidental findings. So it's these patients that are actually common as well where you do a Ct scan or something else, and then, you know, maybe a trauma, and then you find incidental findings.
In an emergency medicine physician's mind, an incidental finding that's not compressing something that's not making someone sick at the time. Might just be out of sight out of mind. And I know they did a study showing, you know, how many times these quote unquote were actually put on discharge diagnoses, and it was really low, like, 27 percent. And it's important to realize that even though we are, you know, the acute dermatologist,
these are also important as well. So if you don't mention it to your patient who have baseline probably doesn't even really have a good understanding potentially of medical conditions. That's where we can fail really bad as emergency medicine physicians. I wanna have us think of ourselves as not just isolated, you know, doc in a box This is my shop, but we are a part of a
great continuum. And fortunately, unfortunately, like you said, we will probably be the first providers to actually see and potentially diagnose cancer, whether we like it or not. I think that's a really important point in that communication is very key in all of this. Monica, I kinda walk us through, a conversation discussing that new found potential for cancer with a patient? Like, what are the components that we need to communicate to our patients?
There are a few main things that patients want to hear. The first thing they'll ask is is a cancer. And the thing is, I don't want to say that we shouldn't be throwing out the word mali malignant or cancer to these patients because sometimes being direct is important. But since we're not oncologists, and since sometimes findings that look like potential mali actually aren't. It's really important to be sensitive about this. And so what I like to say is
I have found on said Ct scan. Something that is suspicious that really needs close follow up. And then I can give a few things like, It might be a concern for infection, it might be cancer. It might be a lot of things. And the reason that I want you to follow up closely is that I don't know what it is, but we need to work it up further. And so it gives the patience an idea of why they need to follow ups soon, but it
doesn't lock in a diagnosis. And I think that's really important because we, at Md anderson get referrals for a lot of possible cancers and the patients have been told, you know, that it's cancer, and then we have a suspicion of cancer clinic, and after biopsy it actually isn't. And so they went through, like, 2 months of anxiety when it was something else. Yeah. I I think that's why I asked that question because in the emergency department, you know, pre biopsy you know, minimal labs,
not a specialist. I struggle with putting that big c out there. You know, and that is really a fork and a erode for so many patients and families that changes the way that they live their lives and think about their future. And so... But you also want them to take it seriously And so, like, that balance is is really tough. But I think it is important to give a gravity to that conversation so that they get that proper follow up.
Yeah. You know, I've been in too many of these where I am unfortunately giving some news of a new finding that's concerning for cancer. So how do you decide which of these findings might be concerning enough to warrant an admin today for an expedited work workout versus follow up in suspicion for cancer clinic.
Really is practice specific because you have to take into account the patient, your practice environment and availability of the oncologist for you to even discuss these cases with because I know a lot of our colleagues, they probably can't pick up a phone and talk to an oncologist. And so do you trust that they will follow up?
Because that's really important too. Do they have the wherewithal and the resources to be able to you know, say, hey, you know, in 2 weeks, I want you to go to follow at this clinic appointment. If they can't even make it to that appointment. If they don't have a ride, things like that. That's going to be a really big issue. So patient specific factors is number 1 number 2. Where what type of practice environment are you
in? Do, you routinely actually get close follow ups because you could put these follow ups in on their dispositions, but how long is the turnaround time? That's something important to think about too. And so the third thing that I think is easier for us as emergency physician. So if you take out all of these other factors, just seeing where these masses are or what potential issues might happen will be important as well because pain is a huge reason in my patients
return to the emergency department. So a mass might not be in a specific area that might be compressing something or you know, your laps might not be showing, you know, an anemia that is borderline needing transfusion, but not yet. So subtle things might actually be even bigger reasons why you would want to have
closer follow or even admit. And I wanted to just highlight cancer pain as 1 of them because in the general patient population, there's been a pull towards you know, not wanting to prescribe too much and really being very cautious. And while you'd still have to be cautious in the cancer patient population, pain is real and the amount that we usually prescribe for the general patient population will not
be sufficient. So if a patient came to for abdominal pain with their newly diagnosed colon cancer. And, you know, you wanted discharge them home with pain medication, 10 pills is not going to be enough. It's not gonna even get them through, you know, the first 2 days sometimes. And so having that idea of the subtle things or the not so medically catastrophic diagnoses might actually be the reasons for repeat emergency medicine visits is going to be important.
Yeah. And I wanna come back and talk about pain a little later, But as an ear physician, you know, as you mentioned, there are some emergent things that we need to know about So what are some of these emergent conditions that are specific to patients with cancer that we should be aware of? There's a few studies that take a look at the most common visits for patients with cancer visiting the ed, and some of them include pneumonia, gas, fever, of blown pain and Ill.
And so all of these conditions as emerging medicine physicians, we are trained to recognize but everything in the cancer patient population is just more subtle the way it presents. Lung cancer is a fairly common diagnosis in the emergency department, and I wanted to use the lung cancer patient as a case. So they basically will come in about, you know, it comp about 10 to 12 percent of cancer related emergency department visits in overall. And
the admission rate is 66 percent. And so with this type of cancer, what you're going to be seeing is besides fever respiratory symptoms, so worsening effusion along with neurologic issues. Other things to think about are subtle presentations like just feeling fatigue can also indicate electrolyte abnormalities or anemia. Things like that as well. Can you speak to the neurological issues? Like, what you mean by that specifically Monica?
Sure. So, unfortunately, a lot of times, patients present to the emergency department for the first time, for their first diagnosis, and they were previously well. And they might have had just, you know, subtle symptoms, but neurologic findings that does indicate that there might be a meta to the brain. And when you think of patients that come to the emergency department, a lot of times
it's for acute issues. And so that's 1 of the reasons why they would they would present either seizure activity, really bad headaches and unfortunately, sometimes even altered levels of consciousness due cerebral edema from meta. So really any subtle neuro based symptom or sign should be taken seriously in our patients. That have cancer. Like, we should really slow our role and stop and think about it. Is that fair to say?
I think it's such an important thing to highlight even with trainings that come through emergency department, when you think of the, you know, the path and monica findings, for certain things like core compression as an example, you want to actually catch things before you find these lower motor neuron symptoms. You wanna catch things before there is a problem that potentially can't be reversed. And so just presenting with pain. A lot of times these patients have had back pain for a really,
really long time. And they have either seen their primary care doctor. Maybe they've gone through other emergency departments. You want to be able to catch that meta ta at that time. With early cord compressions that you don't find the... III call it the end symptoms because once you an end symptom. It's harder for radiation oncologist or nurse neurosurgery to really interact with things and make them better.
So, Monica, I feel like 1 of the other common things I see in the Ed, often with the initial presentation of cancer or sometimes the way we find the cancer. Is Dv or Pe. So, you know, they come in and we end up diagnosing that, and then through some of those studies, we end up also finding a potential mali. Is there a different way that you would treat Dv or Pe in a patient that you also had a concern for new cancer? Is that something that would warrant admission? Or how do you approach that?
So at Md Anderson, we have our own algorithm, and a lot of people are surprised because we send a lot of patients home. Not all Dv or Pe require emission? And so there is risk strat justification. Are they symptomatic when they're am, do they saturate? Do they get tachycardia even on Ct, if it's a pulmonary embolism, is their evidence of right heart strain or, you know, with bedside ultrasound. And so if you are in a intermediate to higher risk, it does warrant some
observation or admission. But a lot of these times Dv and Pe can be found incidentally, and a lot of these patients can be sent home. The big things that I will always ask is is there a bleeding risk? And then also, sometimes, these patients have not had any imaging of the brain to make sure that there's a meta. And so I ask questions that might indicate that there might be something neurologic, like headaches, vision changes, stuff like that. Also certain cancers just tend
to bleed more. And so I'm more cautious. Like melanoma, I am more cautious to prescribe anti to these patients because when they're on it, if they do have an intra meta, it bleeds, and it's pretty bad when it does. Monica, once patients are started on their appropriate therapies, radiation, chemotherapy, res reception, whatever it might be there are way too many complications to all of those
interventions to hit all of them today. But if we're just kinda, like break it down as to what are some of the common things we see about. 1 of the ones that I feel like we run into a lot. Maybe you can tell us the data on that is Feb ne? Okay? So what is the latest approach to these patients? Like how fast do we need to get antibiotics in What labs do we need? What's our dis on those patients. Walk us through feb ne?
There's a lot of data that is showing that the sooner you get the antibiotics into these patients the better. And so there's a lot of metrics even at our institution. You're... Once they hit triage, that's when the time starts. And so it almost is, like, treating a patient with stem or a stroke. So the clock starts, and you really need to be getting antibiotics into these patients within the hour, ideally 30 minutes.
And I do wanna just add a little caveat for antibiotics because a lot of times, we think antibiotics they need Van and a broad spectrum beta lac antibiotic. And so I see a lot of times everyone does the combination, but you actually only need 1. You only need to add brush spectrum beta lac antibiotic. And so mono therapy that has your anti activity like ce is fine. You don't need to add the van of my son unless you suspect Mrsa.
But the time that you initiate antibiotic administration really does matter. I think they did a study where they basically looked and saw what the mortality risk were. And basically, if you get antibiotics in before 60 minutes, the decrease is actually significant. And for each hour of delay that you have it increases risk by 18 percent. Now on the other side, a lot of colleagues when they come to md Anderson are surprised that how many people
we discharge. And The goal is trending towards trying to transition them to home sooner in a certain subset of patient population. Also, feb ne is not treated the same with hem mali, like lymphoma leukemia, myeloma as solid tumors. So solid tumors depending on if a patient is able to follow up if they live within for us I think it's a, like, a 30 minute radius. We can actually discharge them home if they're reliable.
And so we do it outpatient ne panic follow up for patients that if we actually work them up in the emergency department, and they don't have a source of infection, we can send home if they're reliable take their antibiotics if they can come back for their, repeat labs as well. Solid tumors. Yeah. Solid tumors. For liquid tumors,
that's not the case. Liquid tumors they get admitted because they just have a higher higher risk for morbidity and mortality And the way that you can determine for solid tumors in the emergency department, they, they do have a mask score and so mask stands for a multi multinational association for supportive of care and cancer. And it's an index score that basically when you apply to the onset fever and take a look at the the criteria. If the score is less than 21 points. There's a low risk.
For mortality, and you can you can consider saying them home. What do you recommend? Do you give a dose of zone for those patients that you discharge so that you have that kind deb effect in last seen 24 hours Monica? Or do you just go with that dose pain when you're discharging, the patients that can go home? So how we would do it is if you're not panic, and if there is no fever source, you might not actually get sent home on antibiotic.
Especially with a lot of these, you know, viral illnesses that are going around that sometimes the viral panels don't check. So the patients that are potentially okay to send home would be solid tumor patients that do not have a source of infection found on your work up, the source. Being when you do a chest x rate to look for pneumonia along with a your analysis to make sure that there's no urinary
tract infection. I will put a caveat in for the respiratory infections because if the patient is symptomatic enough, it might warrant observation even though there isn't antibiotic or a treatment you need to give. But for the patients that are well appearing. At md Anderson, we have a outpatient ne panic fever pathway, and there are some criteria. So the patient has to live within an
hour away from our institution. As well as be reliable to be able to come back for further work up and be able to tolerate oral to take Antibiotics and also have someone with them to monitor things. And if you are gonna send these patients home, then the antibiotic choice you give them 2. First line therapy can be super in, 07:50 milligrams po twice daily. Plus a slash acid, and that is for 7 days. And if there is a documented like, really serious beta.
What you can do is tip and cli mason, 600 milligrams. Po, 3 times a day for 7 days. So Monica talked to me about tumor l syndrome. When should we be looking for that in the Ed and what kind of work workout should we be doing? With tumor l syndrome, you have tumors that are high risk that have high risk tumor burden? So think of your advanced b lymphoma, advanced leukemia or even your early diagnosis of leukemia. So liquid tumors.
And then you can get it sometimes in the solid cancers, but think more of when the patients are receiving treatment because usually, with tumor syndrome for the for lymphoma and leukemia, it's pre treatment with the solid tumors, you think of it after post treatment when the tumors are l. But the thing that I want to share. And again, I keep on saying this over and over again is subtlety. Because you wanted to catch things early on. Most of these patients if they are solid
tumors They will have had labs previously. And so there's grading criteria for tumor l syndrome. And so on your lab values, they might not be super high, but the trend has been higher. And these oncologists teams really definitely take that seriously and in our institution will actually put an observation or admit for early tumor l syndrome. There are lab values that normally we don't routinely get as emergency medicine positions. And so if you are suspecting that you have a patient that
presented with fatigue of possible new leukemia. You need to add these slabs on such as uric acid and L. I think those are the 2 main ones that we don't think about. That are important. But with tumor l syndrome, you have laboratory criteria and clinical. And for us really clinical, it it's all about trends. So if the clinical Tls is, like increase crab, 1.5 times upper limit of normal. So that's easy for us to look at. But then the other criteria is like cardiac arrhythmias or
sudden in death and seizures. These are end stage things. So I don't wanna, you know, put on my diagnosis clinical Tl. That means that potentially, we've missed it multiple other times. And so that's why I wanted to just kinda put in a plug for making sure to look at trends instead of just the actual laboratory clinical because catching things early is important. Are there any specific symptoms that might tip you off to be looking for tumor l syndrome? That's the problem.
Everything is subtle when you think about a logic emergencies. For tumor, it might just be fatigue. It just might be some decreased Po and take
and decreased urination. And so being able to pick up on these subtle sides, I think it's important because we're taught to look for, you know, bigger findings even on r board to these big findings, but it's the subtlety that I think is the most important to remember that once you see patients that presents with your altered mental status with, you know, your arrhythmias, that's a bit late or a lot late. I hate to see a child come into the emergency department with mu.
Talk to us about which groups are at highest risk from? And then I think we can all kind of visually see that diagnosis. But, like, what can we do to help our patients with mu? I think patients receiving radiation to, you, the head and neck are really at most risk because It's not just the pain, but it's also being able to hydrate. And so with the dehydration, everything gets worse as well. And so I want to put in a plug to get specialist onboard early if you have the resources.
I think that's the most important thing because mu is not going to go away. A lot of times these regiments, for radiation, it's multiple times. And so someone needs to be following up to make sure that symptoms are improving and to catch things early. A lot of times patients might need hydration, hopefully not in the most, but it can
be set up as an outpatient. And so we have our palliative care services that help with symptom management and getting them onboard early, not at end of life is going to be the most important because I have a few medications that I can prescribe from my toolbox but really, it's the follow ups. So if I just discharged on this medication in 3
days did it help. And if it didn't, having someone in the outpatient setting, be able to work with that patients that they don't come back to the emergency department even worse than before is going to be the most important thing. What medications do you usually prescribe for somebody who has mu? So you can do topical mouth washes. And rinse for treatment, there isn't in a 1 size fits all approach. So sometimes vis lid might help as
well. But personally for me, I'm not as successful in treatment. That's why it's 1 of the things that I actually get my palliative care colleagues on board early. Because it is very, very difficult to treat. Things that you shouldn't use, I think I just wanted to highlight as well. Ci fate isn't as helpful for radiation, induced oral mu. And then another thing is sometimes you will need to use systemic anal logistics. Like oral op. That's something for for us that we use
quite commonly. It doesn't target specifically the area but but it does help as while. And so doing a, you know, topical mouth washer rinse and then giving an oral anal music is something that I usually do in the mercy department. Another very common thing that patients come in with, especially those who are currently in treatment. The are coming in with nausea or vomiting. And they've already tried whatever they have at home
and they still can't keep anything down. So they end up coming to the Ed. Do you have any recommendations for approaching treatment for these patients. Nausea vomiting is notoriously difficult to treat. I think education is important because sometimes you think that the patient has failed their medications, but they weren't educated to take something around the clock, or they didn't have, like, a first line and a second line agent that you could alternate as well.
We have an observation unit because sometimes even with the best intentions and then the patients have tried their best it just doesn't work. And so making sure that you have a low threshold to act really observe or admit these patients important to because getting dehydrated and not being able to tolerate Po also has its issues and things can go downhill really fast.
Consider observing them for some prolonged Iv fluid hydration because a lot of times, there's no overnight magical pill that'll make things better. And is on, your go to anti. I have generally been taught that on oncology patients often get very high doses of on So what is your threshold? How high do you go in terms of dosing? And are you getting Ekg to check their Q?
A lot of our patients have Ekg already, but if they don't, prior to starting Z, I actually will get an Ekg just to get a good baseline because to be honest, most of the anti medics cause some sort of, like, Q prolong. There's always the side effects that we need to just make sure at baseline we're not making anything worse. Z is our go to. It's even on our order sets. I don't know how high you guys do for regular because I haven't seen a regular quote unquote, like a regular
patient in the general population. But we we start off with 8 milligrams. We don't really keep on trying the same medication once 8 milligrams doesn't work because there's many different types. That you can use. And so using a different medication as a second line is what I and what we do at Md Anderson. If z, 8 milligrams milligram didn't work at that time, then we'll switch to something different.
What about chemotherapy induced diarrhea, how do we help those patients that are having per diarrhea. I sound like a broken record. Everything is subtle. Even if the patient isn't having explosive diarrhea. Sometimes they're really embarrassed to say how many times, but ask how many times. This is a a story that I had when I was a fellow. You know I said, how many times have you been having diarrhea only once, but it basically was a cost leak the whole day.
So that's that's pretty bad. Isn't it? But but it's important to know that patients receiving chemotherapy treatments and other therapies. When they start having diarrhea, they're just more frail. And so have a lower threshold to actually and I and it like, this is why it sound like broken record, observe the patient or admit them for Iv hydration. Also, it's important to find out why they're having the diarrhea. We like to think most common things are common. And so
we'll be the first to say, okay. It's just due to chemotherapy. But In this patient population, I think it's important to also make sure that our first offer for diagnosis is actually true. So sending stool studies, making sure that it's not due to colitis because cancer therapeutics have changed dramatically over the last 10 years. So when you say someone's on chemotherapy, the first thing that comes to mind in my head is, are they only on chemotherapy?
Or have they had a treatment prior and then they're back on chemotherapy? Or are they chemotherapy planning for another different treatment because it changes things. A lot of times chemotherapy now are used in conjunction with immune checkpoint inhibitors, other treatments. And so when you say chemotherapy related diarrhea, it could actually potentially mean an immune checkpoint inhibitor diarrhea. And there's grading skills for that and treatments that need to be followed if it's
due to that. And so if the patient has on immune checkpoint inhibitors, do a Ct scan. If you find colitis, that is also concerning other labs for me checkpoint inhibitors would be Es Crp, checking if other body systems are affected like, adding a Tsa chunk because that's usually silent too. So doing more of a work up than what you would normally do is going to be the most important for these patients even with chemotherapy and do area. Make sure
it's not c diff. A lot of times these patients have had antibiotic usage prior. It's kind of a big black box of babies. The next thing I wanted to get to is anemia and t. Because I know that this may be managed differently in our oncology patients than in our patients without cancer. For us, if the patient has hemoglobin below 8, then we routinely trans, but most of our patients are walking around with hemoglobin less than 12. For sure. Platelets
will be less than 15 trans fuse. That's our criteria. Monica, some of our patients come through with radiation specifically as a treatment modality. What are some of the complications that are specific to radiation interventions. So it depends on the area that's being radiate. But we already talked about or having bowel absorption symptoms, diarrhea, if you're getting it to your thoracic area having p, and p is a little bit difficult because... It can present with a lot of symptoms
that are similar to pneumonia. So those are some of the common things that you will see with patients with radiation. I also wanna say with patients with radiation, you have acute symptoms, but also don't really about chronic symptoms. And so a lot of times in the emergency department, we all always think about, you know, what brings you to emergency department. And your time to present illness is, you know when the last 2 weeks or 3 weeks.
And you don't think that certain things that happened maybe a year or 2 years prior could be the the reason for that. Radiation side effects There's a lot of chronic complications too like diarrhea and m absorption and p meningitis as well that can present long term it's a reason for patients to represent to the Emergency department too for the chronic complications.
Communication with the patient is key. When you find something that might be cancer, please tell the patient put it on the discharge summary and help with the follow up, but don't lock in the diagnosis. Feb Ne. Antibiotics need to be given within 1 hour of hitting triage ideally within 30 minutes. Treat with ce and Van mice if you suspect Mrsa. Standardize with order sets and policies and set up discharge and ad criteria with your colleagues.
When it comes to tumor l syndrome, it is important to look at trends not just the current values. You may catch it early if the values are trending up. Mu is tricky to treat and worth involving specialist for treatment and disposition. Nausea and vomiting can be a sign of something greater. Dehydration can be problematic and hard to treat, so consider admitting for Iv fluids and figuring out why we have the nausea vomiting. You can use z, 8 milligrams right off
the bat. If it doesn't work, the first time they'll move on. Just like vomiting, diarrhea can also be a symptom of a more complicated diagnosis. Consider Iv fluids and observation. Most of these patients have abnormal platelets and hemoglobin levels. Refer to your local policy, but a good baseline is to trans fuse Rbc for hemoglobin less than 8 and platelets less than 15000.
Remember that any neurologic symptom in a patient with cancer can be a sign of something more serious, and often requires further work up. Don't blow these off. Okay. That was a lot, but there is still more to become because this is a big topic. And as we now know, 1 that people do entire fellowship about. So join us next time for part 2 when we talk about pain management goals of care in the Ed and a
few ethical dilemma. Thank you to our department for doing process improvement projects to improve the care of this population of patients. And thank you to Owen productions for improving our production quality. Until next time, stay curious, stay transpired, and stay tuned.