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It turns out that the Mayo EM program has a little room9er of their own… except it’s public… and updated frequently… and has a fellow generating content for it. Truthfully, it’s a great site. Quite a few reviews on topics that don’t pop up on the other FOAMed sites (the killer rashes, retroperitoneal hematoma, tumor lysis syndrome). Worth a look if you’re stuck at Jewish South with a broken CT scanner).
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.
Here is a nice article, one of the simplest but
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.
A middle age male with history of HTN, smoking, and seizures presenting with “mini seizures” since last night. History of a TBI and subsequent seizure disorder back in 1998. Takes phenytoin for it, used to be on phenobarb as well but was taken off of it 1.5 months prior. His seizures have been of the generalized, tonic/clonic variety in the past. Since last night he has had L sided numbness on his face/arm. They have been episodic, coming every 10 min, and they last 2 min. He feels some “clumsiness” in that arm during these episodes but no reported weakness. No difficulty in speech/vision/swallowing. No fevers/chills/LOC/convulsive activity noted.
Phenytoin Level: 14.7
Labwork unremarkable
CT head: negative for acute pathology
Stroke or seizure? I wasn’t sure and I had the attending meet the patient as well. Both of us felt like these were probably seizures. Now I very rarely call neurology about seizures but you can make the argument that this is status so I called them. However, they informed me that isolated sensory symptoms for a seizure is VERY rare and that you are dealing with a possible stroke until proven otherwise. That was news to me, but to his point this was the first case I’ve seen. Anyways, we got the MRI/MRA and they were negative. His EEG showed multiple R sided epileptiform discharges. Loaded him with keppra in the ER, and a repeat EEG improved the seizure activity noted symptomatically and on the EEG. So yay, no stroke!
Main reason I point this out there is to avoid the pitfall of missing a stroke, as Neurology themselves were highly suspicious. Our initial thought process ended up being right, but in order to get there, the point here is to rule out stroke first! Same thing with a Todd’s paralysis BTW. Rule out stroke before you start making that assumption!
I think I’ve shown this to a few of you, but this is an interesting article Droperidol Article
Kind of amazing how some extremely dubious data can affect clinical practice for years, and take a great medicine out of our hands.
Also, do you think these QT concerns that we are now hearing about with Zofran have anything to do with the fact that its now waaaay cheaper than it used to be? No one seemed worried when it was raking in the cash.
Fall: it’s that time of year when the PGY-1s start holding down the MICU.
If your MICU experience is like mine, you’ll get a few texts on the overnight from the medicine PGY-3s asking for help placing central lines. I’d put in a couple subclavians in the OR as a medical student and the venerable (legendary) Jason Mann had shown me some tricks, but I was definitely nervous being the go-to person.
Found these great videos for EM docs on central line placement. Most of the videos I’d seen before were showing you how to identify landmarks and such – these are a level beyond that and offer some great information and tricks for more expert line placement. Worth watching about once a year through residency.
Here’s part 1. Just search for parts 2-5 if it’s helpful.
Nice little post from EM Lit of Note on how to increase patient satisfaction scores. Hint, has nothing to do with quality medical care.
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
Can’t get pain meds after KASPER exposed your nasty habit, so you turned to your old friend heroin? Or you can still get your pain meds, just haven’t learned when enough is enough? Is the fear of stopping breathing really putting a damper on your narcotic addiction? Have no fear, Evzio is here.
This is old news as it was FDA approved in April, and my friend from NY says it is already being used there, but I hadn’t heard anyone talking about it. Evzio is similar to an EpiPen, but delivers a single dose of 0.4mg of naloxone instead. Once it is turned on, it gives verbal instructions in how to use it. It is now available by prescription only.
Has anyone written a prescription for this, or do you see yourself doing so in the near future? Obs your heroin addictions, give them a prescription, and out the door? Not sure how much it costs, but I saw one report that it may cost as much as $500. Goodrx.com lists the price as $591 for one kit of 2 autoinjectors, with a coupon.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm
http://www.nytimes.com/2014/04/04/health/fda-approves-portable-drug-overdose-treatment.html
Here is a newer copy of this powerpoint, updated from a year ago. Enjoy
Nice little post from Lauren Westafer, who just finished medical school and is fairly well known amongst FOAMers (FOAMeders?). Reminds us to be tentative about accepting everything we read on the internet.
She apparently gave a SMACC talk which is a pretty big deal. I was linked to her post on the Life in the Fast Lane weekly review, which I consider pretty much the best roundup of FOAMed on the web.
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.
Here is the powerpoint. Enjoy.
Here’s an excerpt from our ED-Public Health website (http://www.edpublichealth.com):
ACEP’s contributions to the Choosing Wisely Campaign
At ACEP13 last October in Seattle, the organization announced its 5 contributions to the Choosing Wisely Campaign. Initially started by the American Board of Internal Medicine (ABIM) Foundation, the Choosing Wisely Campaign was a response to the movement towards improved healthcare efficiency and a need to decrease unnecessary/low-value procedures and tests. Despite ACEP’s original reluctance to join, in February 2013 ACEP jumped on board and began creating their list of recommendations. After extensive review by an expert panel of emergency physicians and the ACEP Board of Directors, ACEP’s Choosing Wisely recommendations were released.1,2 They include:
1. Avoid Head CTs in ED patients with minor head injury who are at low risk based on validated decision rules.
2. Avoid placing indwelling urinary catheters in the ED for either urine output monitoring in stable patients who can void, or for patient or staff convenience.
3. Don’t delay engaging available palliative and hospice care services in the ED for patients likely to benefit.
4. Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.
5. Avoid instituting IV fluids before doing a trial of oral rehydration therapy in uncomplicated ED cases of mild or moderate dehydration in children.
You be the judge.
Here is a list of pros and cons formulated based on literature review, articles and editorials from other emergency physicians (EPs).
Pros:
1. Reduce cost without affecting quality of care.1,2
2. Improve efficiency.1,2 Example: shorter LOS if imaging is involved
3. Encourages shared decision-making between patients and physicians.1,2,8
4. Medical benefits: Less ionizing radiation exposure, less risk of antibiotic-resistant organisms, fewer catheter-associated UTIs.1,2,4
5. EP-generated, EP-approved. EPs are identifying “low value” procedures/tests for their own speciality, rather than letting others define these for us.1,2,6 For example: the proposed, but ultimately rejected, CMS “use of Brain CT in the ED for atraumatic headache” measure was created by CMS without EP input.8
Cons:
1. Lack of advocacy for medical liability reform.1,2,5
2. EPs have no right of refusal to our patients.5
3. EPs often pick up the slack for other doctors.5
4. Will it come to a point where these 5 tests/procedures will be uncompensated?5
5. Loss of autonomy.6
Other lists of over-used and “low value” tests exist out there. Most notable is a list of 5 tests which was created by EPs and mid-level providers from six Partners Healthcare hospitals near Boston. Published in JAMA, this list was designed to be “actions a specialty provider”7 can take.6,7 They include:
1. Do not order CT of the C-spine for patients after trauma who do not meet NEXUS low risk criteria or the Canadian C-spine Rule.
2. Do not order CT to diagnose PE without first risk stratifying for PE (pretest probability and D-dimer tests if low probability). (included in ACR’s Choosing Wisely list)3,4
3. Do not order MRI of the L-spine for patients with lower back pain without high-risk features. (included in AAFP’s and ACP’s Choosing Wisely list)3,4
4. Do not order CT of the Head for patients with mild traumatic head injury who do not meet New Orleans criteria and Canadian CT Head Rule.
5. Do not order coagulation studies on patients without hemorrhage or suspected coagulopathy (eg: with anticoagulation therapy, clinical coagulopathy)
ACR = American College of Radiology, AAFP = American Academy of Family Physicians, ACP = American College of Physicians
Bedside actions: to begin incorporating these EP-approved recommendations into our daily practice in an effort to institute cost-effective quality medical care (ideally before private insurers, CMS, or other specialty societies begin mandating us to do the same)
References:
1. ACEP Announces List of Tests as Part of Choosing Wisely Campaign. ACEP Clinical & Practice Management. October 14, 2013. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
2. ACEP Prepares List for Choosing Wisely Campaign. ACEP Clinical & Practice Management. Downloaded from http://www.acep.org/Clinical—Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/.
3. Choosing Wisely Master List. www.choosingwisely.org. Downloaded from http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf.
4. Mahesh, M. and Durand, D.J. The Choosing Wisely Campaign and its Potential Impact on Diagnostic Radiation Burden. J Am Coll Radiol. 2013; 10(1): 65-6.
5. Seaberg, David. Pro/Con: Why ACEP Should Not Join the ‘Choosing Wisely’ Campaign. Emergency Physicians Monthly. Published August 24, 2012. Downloaded from http://www.epmonthly.com/features/current-features/the-wiser-choice-should-acep-join-the-choosing-wisely-campaign-no/.
6. Schuur, J.D., Carney, D.P., Lyn, E.T., Raja, A.S., Michael, J.A., Ross, N.G., and Venkatesh, A.K. A Top-Five List of Emergency Medicine: A pilot project to improve the value of emergency care. JAMA Intern Med. 2014; 174(4): 509-515.
7. The Tale of Two Lists: Procedures to Avoid in the ED. Acute Care, Inc. Published February 25, 2014. Downloaded from http://www.acutecare.com/the-tale-of-two-lists-procedures-to-avoid-in-the-ed.
8. Venkatesh, A.K. and Schuur, J.D. A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care. American Journal of Emergency Medicine. 31 (2013) 1520-1524.