A couple cool articles in Academic Emergency Medicine and Training (AET)

1. One simply surveyed residency programs to see if we try to impart efficiency skills to our residents. Overall yes programs do try to educate on this topic. “Results: We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with “signifi- cant” or “moderate” priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: “individual data provided along with deidentified rank” (35%), “data provided only during private feedback meetings” (26%), and “no data or rank provided to residents” (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions.”

2. But the NEXT paper is much cooler. This one looked at what on shift behaviors actual correlate with improved efficiency of residents. Now the outcome metric they used was RVU/hour (they talk about using patients per hour but don’t really report the data in results). I am not sure if I would place your RVU per hour as a top priority. But in measuring efficiency and helping you in your job on graduation, I guess it is ok.

The results were interesting. Seven behaviors correlated with improved efficiency, three with worse efficiency, and a bunch with no difference. Now some of the more efficient ones were found to correlate with LESS efficiency in a study they did in community docs. And some of the less efficient ones were more efficient in community docs. So you have to read the discussion section of the paper.

But one major take home point that they wrote a whole paragraph about that you can do TODAY is “swarming.” This is when you go in with the nurse (and other staff) and take history with them while communicating your workup and treatment plan to the team. This improves your efficiency in seeing patients and everyone wins. I do this at Jewish, often at South the nurse wants to come in the room when the doc goes in. This communication helps and prevents the need to check back with the RN/Tech/RT to go over the plan. So today or on your next shift, try some swarming!

See below, as the variable increases, so does your RVU/hr. Makes sense on some, higher patient load means more RVU. But some cool ones like the more you use dictation, the more RVU. The more you use smartphone to communicate with people in the ED, the more RVU. Oddly, the more nonword tasks, the more RVU (might be that more efficient residents have leftover time to talk to people or do nonword tasks). Visiting the patient room multiple times meant less RVU per hour (but almost definitely happier patients!). Talking to the attending means less RVU (you aren’t billing patients when we talk), but likely more education for you. You see why using RVU/hour is a measure that does not equate to good patient care or even a good work experience for you. The business of medicine : /

More efficient: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour).

Less efficient: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour).

Check out this article by Louisville cardiologist John Mandrola. It is worth reading in full, just one and a half pages. Mandrola and coauthor Foy comment on an iatrogenic coronary dissection during a cath performed for a + troponin in SVT. Check out Table 1, very nice for conceptualizing Troponin elevation.

The TL;DR: carefully interpret troponin elevation when you do not suspect a type 1, acute coronary occlusion MI. As I always tell you guys, a very important binary to collapse in ED patients is, does this patient have an acute occlusion, or OMI.

If you are ordering a troponin in a patient with tachycardia from fever, SVT, afib, or even bradycardia, be prepared for an elevation. But unlike STEMI or STEMI equivalents (ie OMI), this troponin elevation may not require any specific treatment, especially cardiac cath. Treat the underlying condition, even if using troponin as a prognostic marker. This applies more for cardiologists, but we have a role as well. For instance, Amal Mattu says to not even obtain Trop in young healthy SVT patients (I agree).

Sepsis Review- Dr Shoff

What is sepsis? A systemic response to infection
Mortality reduction in sepsis? ANTIBIOTICS EARLY
SIRS- T 101F/90, RR >20, WBC >12k/10% bandemia with evidence of End Organ Dysfx
Severe sepsis += hypoperf despite adequate IVF resus.-30ml/kg crystalloid, or a drop in SBP drop by 40 mmhg, or any SBP <90mmHg
What do you do?
Within 3h of presentation get:
1. Lactic
2. Blood cx BEFORE abx
3. Broad spec abx coverage=zosyn, cefepime, meropenem, ceftriaxone, unasyn, amp, levofloxacin

Within 6h

Within 6h, rep lactic in first is >2h.
Pressor if ivf persist
If lac >4h rept vol status and tissue assessment
If hypotensive after ivf, repeat vol status and tissue assessment.

TIssue assessment/vol assessment?
Vs
Cardiopulm exam
Cap refill
Peripheral pulse eval
Skin exam

Exclusion crit
Comfort care
Death within 6h
Transfers from osh
Refusal to care

How do we do?
-90% bundle compliance

MCC of sepsis @UofL:
PNA
UTI
Skin/soft tissue

MEWS-used as a trend, if trending up=patient getting sick
Patient with BMI >30, can use Ideal Body Weight for fluid resuscitation

Things I wish I knew in residency-Dr. Gall

Eval where you want to work-shadow, see how RNs interact with staff
Less than 12h shifts are optimal
Overlap at shift change is beneficial
Nocturnists work less shifts, more $/hr
Negotiate your contract! -no malpractice without tail
$$- invest in broad index fund if you’re gonna play the market
Live below your means-work bc you want to, not because you have to
Keep studying
You will keep getting better
Fly or ground? >1h and critical (will need immediate intervention)= fly–but is dangerous
If issue with a consultant, have them come see the patient or admit patient for obs
Know what chain of command is before your have an issue with c/s
When pacing, consider use of u/s to ensure that you are actually getting capture.
Callback if concerned about a patient
Be nice to your patients
Review your patient prior to dc!
Take care of those you work with!
Apologize-to staff, patients
Books he likes -Rosen’s, EKGs for ER docs by Brady and Mattu, Roberts and Hedges procedure book

Panel

Things to learn before you finish residency-

TPA- talk to stroke team/follow pts whilst here because you’ll have to do it once done here
Chest tubes- percutaneous are more common outside of trauma centers
Ultrasound guided IVs, midlines
Lower acuity/urgent care style cases- we don’t see many here but you will later
It is normal for confidence to wax/wane right out of residency-but this gets better! Trust your training, you have been well trained
Don’t be afraid to call the children’s hospital for advice, not just for transfers
Follow up on patients you saw

Finances-
Pay quarterly taxes if IC
Read white coat investor
Live below your means

Just posting this article here to stimulate some discussion. Now that we sprinkle TXA on basically any body part, we need to be sure to maintain evidence based medicine. I would point out that there is very little downside to TXA. He mentions the HALT-IT trial that DID show a higher rate of VTE events in the treatment group. But most TXA studies have not shows risk of clotting. We also must be aware of the regression to the mean issue, which is probably what occurred in the most recent epistaxis study. For a book that covers this nicely, see this gem.

Again, I am a fan of TXA, and open to attempting treatment modalities with new, not yet gold standard of care evidence. But we must always practice non-maleficence, and must not be tempted by indication creep.

-Huecker

EMS Prehospital US- Dr. Heppner

1. Pre hospital US began in the early 2000s
2. Advantages include possible early diagnosis of pneumothorax, intrabdominal hemorrhage, cardiac tamponade, and tube confirmation
3. Also, may improve triage process
4. Barriers include costs of equipment and training as well as operator dependence
5. Could also cause delay in transport times

Capstone- Dr. Davenport

1. Heterotopic pregnancy risk is 1/100,000
2. Consider this in patients with persistent symptoms despite IUP
3. Zebra diagnoses are rare but still must be considered if nothing else explains the diagnosis
4. Be cautious in pregnant patients if you are concerned with ectopic rupture, even in patients with stable vital signs

Hyponatremia- Dr. McGee

1. For hyponatremia consider history closely when deciding volume status.
2. Primary polydipsia is rare and requires huge amounts of water intake.
3. Doing a repeat confirmatory test on a hyponatremic patient with minimal symptoms is important.
4. Use serum osms to determine pseudohyponatremia
5. In true hyponatremia, sodium and osms are low
6. Low Urine Osms and low specific gravity point to ADH independent hyponatremia, high Osms and SG would suggest ADH dependent
7. Consider Uric Acid test which may be low in SIADH
8. Beware of elderly patients with mild hyponatremia because they are at much higher risks of falls
9. Goal of hypertonic saline is to raise sodium by 5 mEq or improve LOC

Room 9 Follow up- Dr. Thomas

1. 45 yof hx of obesity, HTN, DM, complaint of weakness and slurred speech with a GCS of 6
2. Intubation complicated by black emesis but achieved with reverse trendelenberg position.
3. Head up intubation increases time until desaturation.
4. Consider bougie for increased first pass success
5. Consider post intubation complications when selecting head up vs conventional intubation

Pediatric DKA- Dr. Patterson

1. Pediatric DKA can many varied presentations
2. Blood pressure is usually last thing to decompensate in pediatric shock
3. Don’t bolus insulin initially. Make sure patient is resuscitated and potassium is appropriate
4. 10-20 ml/kg fluid bolus is correct based on PECARN
5. Most new evidence suggest that cerebral edema may be less iatrogenic than initially thought