It was in the huge exhibition hall at the Scientific Assembly in Boston, where we find Ricky Bukata, son of the famous founder of this blog, arranging an audio visual presentation, when a non descript man walked by, unnoticed by any of the 4000 thousand participants. Ricky says to his friend "Hey, you know who that is?" The Friend answered " Dunno- Greg Henry? Ed Newton? No, it doesn't look like any of those- actually doesn't look like anyone interesting at all" Ricky walked over to the mysterious man- "Rick Bukata- nice to meet you- are you by any chance the Mythbuster?'...by Yosef Leibman, MD

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I vividly remember watching the AT&T “You Will” ad series in 1993. In a series of rapid-fire sequences, it described what technology would be like someday. At the time, the commercial seemed like science fiction. That is how I felt walking out of the mHealth conference in Washington DC. Over 2 days in early February, 300 people—coders, policy wonks, executives, and providers—discussed the coming wave of mobile health technologies. Peter Waegemann, Vice President of mHealth Initiative, opened the conference launching into a bold vision of the future where mHealth dramatically changes medical education, consumer lifestyles, provider behavior, and the way doctors and patients communicate. With four billion mobile phone users worldwide, these changes will occur across borders and in vastly different health systems. New technologies raise novel questions with tough answers. Some of the toughest questions center on regulatory mechanisms and reimbursement. Who will pay providers for new ways of taking care of and communicating with patients? Will the FDA and FCC initiate new regulations over innovations?...by Raj Chand, MD

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The Problem --- Are you ordering too many CT scans in your ED? Somebody is. If it’s not you, it must be your partners who are the culprits. I recently looked back at our ED CT numbers from 1999 and compared them to 2009. The numbers are astounding; a three fold increase in CT scans per year over the decade. I can guarantee you that our volume did not increase by this amount. I won’t even tell you the exact number of scans because my thyroid aches just to think about it. From a national perspective, the total number of annual CT scans in the United States jumped from 3 million in 1980 to almost 70 million by 2007 (Arch Intern Med. 2009;169(22):2078-2086) Radiation risk from CT varies with age, sex, scan protocol and machine technology. In one JAMA study, the authors examined the lifetime risk of cancer associated with radiation exposure from CT angiography (CTA) of the chest. (JAMA 298(3):317, July 18, 2007). They noted that the radiation exposure with triple-rule out CTA of the chest was up to 24 mSv; equal to approximately 250 chest x-rays. They argue that the lifetime cancer risk for standard cardiac scans varies from 1 in 143 for a 20-year-old woman to 1 in 3261 for an 80-year-old man. This begs the question, if the risk of cancer in a young woman is 1 in 140 for a single scan, do four scans over several years increase that risk to 1 out of 35? Is the cumulative risk additive, geometric, or even worse? As importantly, any CT we order on a patient today is unlikely to be their last. In a study by Kline, 675 patients who underwent a CTA to R/O PE were followed for approximately 2000 days. Seventy three percent had one or more subsequent CT scans of any body part and 5% had five or more repeated CT pulmonary angiograms. (Ann Emerg Med, October 2008) ---Why the problem?...by Stephen Colucciello, MD

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I went to work a couple of weeks ago and had a remarkable patient encounter. I went to see a 95 year old lady who was complaining of chest pain and dyspnea. I introduced myself; her first statement to me was: "why is everyone making my dying so complicated?" This was a wonderful woman, very alert, with a twinkle in her eye. She had come in 2 weeks earlier with chest pain and a STEMI. Without asking her approval, she was transferred to the cardiac cath centre and had a stent placed "they just told me what was going to happen." Here she was again, with crackles in her bases and signs of an acute sub-endocardial MI on her ECG. So what did I do? by Jim Ducharme MD CM FRCP

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As we left the Mythbuster in the last blog, he was facing off with the chief of staff of St. We Never Change hospital.  Dr. Pendergast has come to the rescue of his beleaguered surgical staff who fell from the evidence onslaught of the Mythbuster

The Mythbuster fires over the first salvo-

Doctor- are you waiting six hours for your repeat enzymes in chest pain patients? Better check out the delta test- that is, if you recheck your enzymes two hours after the first set you will see a change for the worse- see Ann Emerge Med 2004,44:12 and AJEM 2000 18:1.

Pendergast winced

Still using CPK MB because it is cheaper?- well some feel it doesn't work. Circulation 2008:1182200 noted it went up in asthma, PE, head trauma, muscle disease- all in the absence of heart disease. Won't help in renal failure- CPK MB goes up in that too. Troponin isn't the end all to be all either- often goes up in PE, and even in exercise.  Ever thinking about going by clinical grounds alone?

Pendergast staggered.

Telling your EMS guys to put oxygen on all patients with chest pain?  Did you know a meta analysis showed that this may increase infarct size and perhaps mortality? (Heart 2009 95:198) Oxygen causes reduced blood flow to the coronaries.

Pendergast started to look very woozy

Not allowed to shock asystole?  Since 1992 the AHA has been saying no. But there is no evidence it does make a parasympathetic storm that will not allow heart restarting and since fine v fib maybe hard to pick up, there may be benefit to shocking it. (AJEM 26(9)618)

You are an educated man, Pendergast.  All these articles came out within the last year and a half- you are interested in helping your patients.

Pendegast suddenly roared like wounded lion "Take this, mythbuster!" and he whipped out  the ACC/AHA guidelines for unstable angina and STEMI. (JACC 50 e1-157) Mythbuster winced. He quickly turned to the Dogma Devastator and said " Did you mail for help?"

The devastator nodded. 

Pendergast reached for the defibrillator and slowly turned towards the 'buster.  Next time the last in the installment- will the mythbuster be toast?