Archive for category ED Management
The iPhone Alarm Bug has been decimating our department for the past few days — anyone else? Attendings who say they’ve never been late once in “20 years” are oversleeping now, on two consecutive shifts!
There’s a lot of things to like about being an Emergency Physician: the hours, the healthy sarcasm and joke-cracking during a shift, acute pathology, procedures, helping patients; and there’s a lot of things to dislike about being an Emergency Physician, too (you can name your own).
But there’s one thing medically that I can’t stand more than anything else: the NG lavage for upper (or “undifferentiated”) GI bleeds. To me, there’s really no worse test, and here are my reasons:
- It’s a poor screening test. We’re looking for the presence of blood in the stomach. Screening tests should have a high sensitivity, since you want to rule-out disease. And NG lavage simply doesn’t. It has tons of false negatives and tons of false positives.
- It’s brutal. The adage is that we do no other procedure without sedation that is more uncomfortable than the NG tube placement.
- It doesn’t change my management or practice. I find that if patients are continuing to have an active upper GI bleed, I know it by looking at them and their vital signs. They are persistently tachycardic. They are diaphoretic. They pass large clots or melenic stool. They vomit bright red blood or coffee grounds.
Similarly, if a stable, well-appearing patient is pooping bright red blood, odds are it’s probably a lower GI bleed. Have I seen a massive upper GI bleed present as just lower GI bleeding? Yes, in an unstable, tachycardic, hypotensive demented 85 year old woman.
I’m hoping I’m not the only one here who feels this way–but I wonder what’s the bee in the bonnet for everyone else? The CT/LP for subarachnoid? New left bundles with no prior EKG? Renal failure who desperately really needs a CT scan? Looking forward to your thoughts on the NG tube or any other acronym that drives you
to drink mad during a shift.
You know, I like the new New England Journal of Medicine web design, but some of their recent EM-related reviews and summaries have driven me crazy.
Let’s start with Acute Pulmonary Embolism, which I view as a pretty good emergency medicine topic. We’re obviously not the only physicians who evaluate patients for pulmonary embolism, but we’re pretty much the only ones that evaluate outpatients for them. Maybe it’s just specialty pride (and lack of understanding of the Italian health care system), but it seems strange to have a review on “Acute Pulmonary Embolism” written by physicians who hail from the “Internal and Cardiovascular Medicine and Stroke Unit” in Italy. (Especially when Harvard itself has its own PE expert, Chris Kabrhel.)
A couple things rub me the wrong way (and luckily, the comments to the journal say similar things):
- There’s no mention of the PERC rule. The authors presume anyone who is short of breath without any other identifiable cause should get a D-Dimer, which, based on the number of short of breath patients I have, would increase my CT angiograms exponentially. (In a patient with pre-test probability less than 15%, the PERC can get your patient down to a <2% risk of PE.)
- It’s surprising to me that there’s discussion of the data on thrombolysis and thrombectomy but that no high-quality data exists in favor of anticoagulation. Sure, there’s ethical issues (“it’s the standard of care”), but I think it’s at least worth mentioning.
- Finally, fondaparinux is thrown into the treatment mix prominently (“subcutaneous low-molecular-weight heparin or fondaparinux or intravenous unfractionated heparin”) and I’m not completely sure why. Perhaps it’s used much more in Europe than in the US (I have never ordered it here in my community hospital in New York). Also concerning is the fact that the lead author, Giancarlo Agnelli, was both advisor/consultant and member of the Speaker’s Bureau of GlaxoSmithKline, maker of fondaparinux. This is not mentioned in his disclosures.
Next up is Emergency Treatment of Asthma, which, even more than PE, is the bread and butter of Emergency Medicine. Again, it’s not written by an emergency physician, but by Dr. Lazarus from UCSF’s Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute. Just seems a bit strange that “Emergency Treatment of Asthma” is written by a pulmonologist, when their population bias is probably either the intubated asthmatic or the outpatient asthmatic, but not the range of “acute asthma” we see in the ED.
- First is FEV1/peak flow. I know some of my colleagues like to use this for their asthmatics, but I personally don’t. I find that I can typically see which way my asthmatics are going just by listening to them, looking at them, and speaking to them. That is: clinically.
- Second is the workup:
Laboratory and imaging studies should be performed selectively, to assess patients for impending respiratory failure (e.g., by measuring the partial pressure of arterial carbon dioxide [PaCO2]), suspected pneumonia (e.g., by obtaining a complete blood count or a chest radiograph), or certain coexisting conditions such as heart disease (e.g., by obtaining an electrocardiogram).
Where to start: who is still getting ABGs on these patients for hypercapnia? Obviously in the intubated asthmatic, or the asthmatic who looks like they’re tiring out or getting sleepy, but an arterial stick is nowhere near my list of priorities for a tight asthmatic. Next up: the chest x-ray. I typically only get it when the patient is not improving (“maybe it’s not asthma”) or the story is concerning for pneumonia. I won’t even mention getting a CBC to evaluate for suspected pneumonia.)
- I can’t even believe this is really in the table in the New England Journal of Medicine, but it actually suggests that we should be measuring for pulsus paradoxicus to determine who’s a severe asthmatic. If someone could explain this to me, I’d really like to understand its usefulness.
- I’m also unsure as to why inhaled steroids are recommended in this article, when the Cochrane Review did not find any benefit to these (and the Cochrane review includes the cited paper).
- Next, the paper recommends reassessing the patient after an hour of treatment. In my severe asthmatics, this would get many of them intubated.
- Finally, IV magnesium is discussed as an area of uncertainty, but I will typically give it to any severe asthmatic. In subgroup analysis of severe asthmatics, it was beneficial at preventing admission. I find I’m typically throwing the kitchen sink at the bad asthmatic (including BiPAP, occasionally terbutaline) to prevent them from getting intubated.
In summary: New England Journal of Medicine: either cover the diseases emergency physicians see adequately, or I’ll just keep reading our own journals instead.
Wow, it’s already been a year since my last post about World AIDS Day.
- I’d like to highly recommend this edition of EM Clinics of North America, which is a whole issue dedicated to HIV-related emergencies in the ED;
- Please offer HIV testing to your patients;
- Please talk about safer sex with your patients;
- Catholics may now use condoms for disease prevention (not for the prevention of child-bearing).
A video introduction. Sorry for the mumbling.
[vimeo width=”640″ height=”400″]http://vimeo.com/12417068[/vimeo]
(Or: Give Me The Right Answers, ABEM!)Today we residents are post-inservice exam, put together by The American Board of Emergency Medicine, and I can say this about the test: I’m glad I’m not an intern anymore. I’ve obviously still got a lot to learn, but it’s nothing like the feeling of overwhelmth (yes, just made that up) you feel halfway through your internship thinking, “I’m supposed to know the answer to this?”
But today I’m not writing about those mushy-gushy feelings and experiences. No no. Today, I want answers.
I was always annoyed with standardized medical tests (primarily the USMLE) where you left the exam with a) no idea how you performed and b) no real feedback for several months. At this point, I don’t really care if I missed a question about cyclic GMP on USMLE Step I, but for the inservice exam, it’s a different story. This is stuff that I apparently need to know. And so, please, ABEM: I want to know the right answers.
If the point of the inservice and the boards is knowledge and learning and requiring a certain level of competency of emergency physicians, then why not give us feedback so we don’t actually screw something up with an actual patient? What, the answer wasn’t ceftriaxone? Why not? What is it that I’m not understanding about the case that you thought it so important a concept as to test it? If a resident answers that he or she wants to use an ABG to rule out a pulmonary embolism, or decide to get abdominal films as the test of choice for right lower quadrant pain, shouldn’t we be telling that resident (or his or her program) that there’s some serious educating that needs to happen?
ABEM: I want an email with feedback on the questions I missed, or wasn’t sure about. Have me optionally fill out my email address in bubble format, and when you scan through my answers and calculate my percentage, email me the answers. Or, if you don’t want to share the questions because you recycle them, email me the specific topic. Not just “management of status epilepticus,” but “second and third line agents for status epilepticus.” Not just “tick borne disease,” but “treatment of pediatric lyme disease.”
Sonosite has released a FREE iPhone app that will help improve their ultrasound skills.
The videos are amazing! Containing many tips, pointers on techniques, great sample cases, image gallery.
The app even has an abbreviated manuel for the Sonosite. The app also contains the latest news concerning sonosite machines.
Here are some screen shots:
For a sample video click here
If you do not like the app, you are out time but not money.
One of the key ingredient to running an efficient Emergency Room is good communication. Depending where you work finding charts, immediately finding a nurse or calling radiology can take longer than expected. Huntington Hospital is currently using an Iphone/Ipod device that allows the health care staff better communicate with each other. It does this via VOIP (Voice over Internet Protocol), basically the set up the system in the hospital to call each other using these devices instead of the hospital PBX or screaming across the ER. The Voalte One system provides voice, alarm and text services all on one device. Overall helps reduce the noise level and makes it easier for the staff to text each other or call each other.
Over all points:
- Receive Voice calls, alarms, and text messages all on a single device
- Easily manage multiple text message conversations
- Intuitive user interface and ringtones
- Allows simple alarm acceptance or rejection
- Custom, user-generated “quick messages” facilitate instant messaging of common items to other users or a web-based client
Overall I see both pros and cons, on one side I think it would be useful to have one device to do it all.
On the other side, I worry that it might make it to easy to interrupt us from patient care. In the end it is all about the balance act.
Huntington Hospital is a 636-bed trauma hospital. For more information, visit www.huntingtonhospital.com
Company website: www.voalte.com
My name is Scott Weingart. I’m an emergency physician intensivist from New York. For the past ten years, I have been hosting a webtext on ED critical care at EMCrit.org. Over the past year, this has flowed into the free EMCrit blog and podcast on all things ED Critical Care.
Both these efforts have been devoted to bringing Upstairs Care, Downstairs. What I mean by this is that geography alone should not determine the aggressiveness of treatment. monitoring, and comfort-giving in critically ill patients. If the care makes sense and is based on good evidence in the ICU, it should be started the moment the patient rolls through the ED bay doors. Some might consider this far-fetched, but we’ve been trying to make it work for a few years now with some notable successes (and a few set-backs.)
I am pleased to now be able to post my podcasts and show notes here at the Central Line Blog. To start it all off, here are the top 3 posts from 2009:
Sympathetic-surge Crashing Acute Pulmonary Edema – When a patient gets wheeled in with crackles up to their clavicles and a BP of 280/190, the problem is NOT volume overload. These patients need afterload reduction. And if you need to intubate them, it is on some levels a failure [Read More & Listen to the podcast]
Intubating the Critical GI-Bleeder – Nothing is as sphincter-tightening as having to tube a variceal bleed with a belly full of blood. As in so many things, proper planning prevents poor performance. [Read More & Listen to the podcast]
Non-traumatic Subarachnoid Bleeds - A ton of things need to be done in a very short time in these critically ill SAH patients.
[Read More & Listen to the podcast]
I would love to hear your comments and any suggestions for future topics.