Great discussion of the biases and conflicted interests of medical publication. Here is a fun little news story about one of the predatory journals, which we didn’t even get into. Looking forward to another conference dedicated to reading the literature.
I also meant to introduce everyone present to Belinda Yff, our medical librarian. Not only is she invaluable for assistance with literature search, but she completely caters to the Emergency Physician’s unrealistic expectations of rapid results. She completes and sends me literature searches in a matter of minutes to hours, and can borrow articles from other libraries when we do not have access.
I would strongly recommend everyone saving Belinda’s information and asking for her help with research interests and lecture preparation. Her email address is belinda.yff@louisville.edu.
Hey this is not a case but what goes through my own head on a difficult shift. There is a lot of information out there on cognitive load / error. Dr Croskerry is essentially the EM world expert on this subject. Take a look at this most recent article. Another great resource are a couple books, one short and sweet the other very in depth. Both are dirt cheap now on Amazon.
This is a neat party trick I picked up on CCU. Now when a patient comes in with pacemaker malfunction/chest pain/syncope and needs a Cardiology workup and admission, but hasn’t been able to locate their pacemaker card since the mid 90’s, you can look like a pro and know the device manufacturer from CXR alone (which is something we get anyway on anyone who remotely looks like they might need Cardiology).
A couple months ago (during lecture), we had a discussion regarding tPA and acute onset of stroke. As you would expect, we discussed the indications, contraindications, etc of treating stroke with tPA. We also touched on the subject of our role in pushing tPA here at UofL.
Obviously as a stroke center, our stroke team is working around the clock- and as such, generally takes the ball on this one. However, when we are practicing outside of UofL, a stroke team is not always going to be available and ultimately the management will fall on us. Hence the discussion and considerations for us making the call or at least working towards that possibility in the future.
Coincidentally, at precisely the same time as this conversation, a small journal, based out of New England, with a primary focus on medicine, published three fine articles on a similar topic. These articles were focused on the treatment of stroke in the acute setting.
As pertinent to this post, they explored the use of thrombolysis as well as mechanical removal of thrombus when said thrombus is located in a proximal vessel. Now I won’t pretend I can read, but for those of you who can- below, are links to two “previews” and one complete view of the above mentioned articles. Additionally, an audio file is embedded, containing a break down of the articles by Dr. Dave Newman, of the Mt. Sinai School of Medicine in the Department of Emergency Medicine, to be featured on a future episode of EM:Rap.
Ultimately, I guess the questions I have regarding this as a post on Room9er are as follows:
1. I believe the Stroke team has embraced these articles and to my knowledge (as of February) may have moved towards mechanical retrieval of thrombus in proximal vessels in appropriate candidates. If we are trying to move towards a more ED involved decision tree, what will we need to know and where will our policies stem from? At least as a concept. At this time, I have only heard us discuss tPA, but if we as a hospital are moving towards multiple modalities for treatment of acute stroke, should we not be discussing these as well?
2. With consideration of a 6 hour time frame to thrombus retrieval, what is our (UofL) policy on timelines regarding retrieval. (This is not reflecting any current policies, merely one parameter from one study.)
3. How much time is required from page to cath? This is undoubtedly a big question. What does it take to have a vascular team, NES team, etc ready do go. How will this influence our time of onset to treatment guidelines.
4. Outside of UofL, taking into consideration transit time, etc. how will this influence the management of stroke? Based on CTA availability, transit time, local resources, etc.
I rarely use ketofol at Jewish, but will let you guys use it at UL when you want. But this article gives a similar opinion to mine: Ketofol does not hold much benefit if any over Ketamine or Propofol.
For quick procedures where you want muscle relaxation (joint reductions or cardioversion), I use propofol. For painful procedures and trauma patients (traction pins, intubating marginal BP patients, chest tubes) I prefer ketamine.
Propofol with the K does NOT seem to decrease emergence reactions. Though Midazolam does so do give 1-2mg midazolam with your ketamine.
My main issue is anecdotally that the ketofol duration of sedation is noticeably shorter than ketamine. I believe this is due to a lower ketamine dose. And we all know that once the dissociative threshold of ketamine is reached, higher doses simply lengthen the duration of effect. You can’t get “more dissociated” just like you can’t be “very unique.”
I don’t even want to mention etomidate here, as I see only one indication for etomidate (as of 2015 where we are on the brink of taking the head injury stigma away from ketamine).
Another one from Mattu’s Feb review. This article compares psychological stress to physical stress to detect effects on perfusion of the heart. Interestingly mental stress causes ischemia where physical stress does not seem to.
There has always been an intuitive relationship between psychological stress and myocardial ischemia. Bernard Lown, a famous cardiologist, said in EVERY MI patient he had he would find a recent large social stressor in the patient. Of course plenty of hindsight bias occurs here.
Either way, if nothing else with this article remember that emotional stress causing chest pain COUNTS AS exertional ischemic symptoms. The fight with the boyfriend or girlfriend does not allow for blaming the pain on “anxiety.” And perhaps the real stress test in our Chest Pain Center is the 20 hours of sleep deprivation coupled with exposure to yelling, retching and dying that our patients must undergo to make it upstairs for a nice quiet little stroll on the treadmill.
Hey guys here is a relevant (albeit 7 years old) article supporting my abandonment of the CK-MB. I had heard Mattu talk about this on some podcasts but this article (along with some newer ones) is the evidence to support that practice. At Jewish I do not obtain a CKMB though when I want a total CK I now have to remember up front. On the POC machines at Jewish the Trop alone seems to error far less than when CKs are running with it. Still watch out for the Trop false positives.
Also I would plug Dr Mattu’s new ECG site. Now he charges a small fee (can pay weekly or monthly but I did the $27/year). Still video based (I prefer to just read a blog with pics) but top notch quality. There is a weekly case and a monthly lit review. The above article is in his Feb review. Might make a one month subscription part of the ECG month. ECGs of course are learned over years and decades, not in a month long elective.
Here is a nice little article specific to hypoventilation associated with propofol use. The concepts are applicable to all sedations and everyone should read this, quick read and will save you some BVMing or an intubation or a death someday.
We are pretty spoiled at UL with our nurses being the best in the hospital, and being savvy with ultrasound-guided IVs. But when you leave UL to moonlight or graduate and start a new job, don’t expect your nurses to be able to place USN IVs. At Jewish the docs do them all. Nurses in places other than UL are quick to call IV therapy, very quick.
Really cool article with commentary attempting to investigate how experienced docs walk into a room and smell the diagnosis and dispo in a few seconds. Looks like most of the “reasoning” is done before even seeing the patient. Read the RN notes!
As a resident I made a comment about Dr Mallory’s knowing the unteachable. I think this diagnostic skill is learnable but maybe not teachable. It can be called intuition. Pattern recognition. Etc.
DSI works. Weingart’s original article was descriptive. Now he follows with a prospective observational study. I actually haven’t read the whole article yet because like a good book, I just don’t want it to be over. Everyone needs to read this.
Also we all need to quit being slackers on room9er. Lets try to get a few more posts in before the holidays hit us.
As customer satisfaction becomes rapidly enshrined as our reimbursement overlord, we are all eager to improve our satisfaction scores. And, by scores, I mean: Press Ganey.
So, as with all studies attempting to describe patient satisfaction, we unfortunately depend on the validity of the proprietary Press Ganey measurement instrument. This limitation acknowledged, these authors at Oregon Health and Science University have conducted a single-center study, retrospectively linking survey results with patient characteristics, and statistically evaluating associations using a linear mixed-effects model. They report three survey elements: overall experience, wait time before provider, and likelihood to recommend.
Which patients were most pleased with their experience? Old, white people who didn’t have to wait very long. Every additional decade in age increased satisfaction, every hour wait decreased satisfaction, and there was a smattering of other mixed effects based on payor source, ethnicity, and perceived length of stay. What’s interesting about these results – despite the threats to validity and limitations inherent to a retrospective study – is how much the satisfaction outcomes depend upon non-modifiable factors. You can actually purchase patient experience consulting from Press Ganey, and they’ll come teach you and your nurses a handful of repackaged common-sense tricks – but I’m happy to save your department the money: door-to-room times.
Or change your client mix.
Done.
“Associations Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in an Adult Population” http://www.ncbi.nlm.nih.gov/pubmed/25182541
Below is the LITFL summary of another look at the importance of early ABx administration in septic patients. Septic and especially severely septic patients should be taken to room 9, obtain blood cultures promptly, and initiate antibiotics as early as possible.
Ferrer R et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-55. PMID: 24717459
This retrospective analysis of prospective surviving sepsis data of patients admitted to the ICU with severe sepsis found that delays in antibiotic administration resulted in a concomitant increase in hospital mortality. Though the results are compelling with a linear relationship between time to administration and hospital mortality discovered it is key to interpret this study with caution as the data are uncontrolled for the antibiotic administration to time metric primarily studied by this paper. Multiple potential confounders exist that might account for the observed relationship that should be studied prospectively. In the meantime it makes reasonable sense to administer antibiotics as soon as possible after the actual discovery of real sepsis.
Hey guys a long but important post from Steve Smith on AvR ST elevation in setting of ACS, STEMI.
His main point in posting is to emphasize the point that STE in AvR is concerning for Left Main Disease, but NOT SPECIFICALLY Left Main OCCLUSION.
This highlights a consistent theme on Smith’s blog which is our role in differentiating the patients who HAVE ACUTE OCCLUSION, ie STEMI or STEMI equivalent. These patients need emergent cath where others might be best treated medically prior to pulling the trigger for cath lab.
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