Do microaggressions and discrimination impact the patient experience in your ED? How can we address this?
This article is one of few studies to address this topic specifically in the ED. Authors used quantitative (discrimination scale) and qualitative (follow-up interviews) methods to answer this question in two urban academic EDs.
Common themes from patient responses provide food for thought and action in this regard:
- Clinician behaviors: Positive behaviors included frequent communication, reassurance, privacy, respect, and validation of concerns. Empathy and eye contact were also mentioned.
- Healthcare team actions: Positive interactions with clinicians reassured confidence in the emergency care visit and willingness to return for future health care.
- Environmental pressures in the ED: Participants often noted long wait times and busy staff when describing negative ED experiences.
- Hesitancy to Complain: Patients were hesitant to identify staff members, did not feel that the complaint would be acted on, and worried that their medical care would suffer if they brought up their concerns.
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Bag-Valve-Mask Ventilation During OHCA
- Current OHCA resuscitation guidelines recommend a 30:2 strategy of CPR with BVM ventilations.
- Idris and colleagues performed a secondary analysis of the Resuscitation Outcomes Consortium CCC clinical trial to determine the incidence of BVM ventilation during a 30:2 CPR strategy and assess the association of detectable ventilations with patient outcomes.
- In 1,976 patients, the authors found that only 40% of patients had detectable ventilations (> 250 ml) in more than half of CPR pauses.
- For those patients with detectable ventilations in more than 50% of pauses, there was an association with increased survival to hospital admission, increased survival to hospital discharge, and increased survival with favorable neurologic outcome.
- The current study highlights the importance of proper BVM ventilation during OHCA resuscitation and the opportunity to improve performance of this vital skill.
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This study compared admitted trauma patients with alcohol withdrawal or those at risk of withdrawal before and after a benzodiazepine sparing protocol (using clonidine and gabapentin) was initiated. They found a lower daily CIWA score and significantly less lorazepam use in the benzodiazepines sparing group. This sparing protocol appears to be safe and effective.
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The OPAL trial attempted to investigate the effectiveness of opioids in the acute management of neck and back pain.
346 adults presenting to the Emergency department or primary care provider with 12 weeks or less of lower back pain, neck pain or both (of at least moderate intensity).
51% male. 49% female.
Location: Sydney, Australia
All participants received guideline care (advice to stay active, reassurance of a positive prognosis, avoidance of bed rest, and, if required, other non-opioid analgesics).
Patients were then randomly assigned to an opioid (oxycodone, up to 20 mg PO qD) or and an identical placebo, for up to 6 weeks*.
*Trial used a combination oxycodone/naloxone to reduce risk of opioid induced constipation and assist with blinding.
*Trial used a modified release formulation that could be dosed q12h rather than q4-6h to increase adherence.
*Recommended regimen was oxycodone 5mg every 12 hours, with titration as necessary, max dose 20mg total per day.
*Trial physicians were able to individualize the prescription to suit the patient’s needs.
* Mean prescribed dose was approx. oxycodone 10mg total daily.
*Most patients only treated for 2 weeks
Primary outcome: Pain severity at 6 weeks
Results: Mean pain score at 6 weeks was identical between groups.
Trend towards faster recovery in the placebo group in the first 2 weeks.
Take home: Consider the likely benefit vs harm of prescribing opioids for acute back and neck pain in the ED.
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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia. Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included. ROSC rates were 28.6% with survival at 30 days being only 8%. 30-day survival for medical cardiac arrests in this jurisdiction was 16.4%. Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).
Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest. Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide. While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.
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Post-arrest shock is a common entity after ROSC. There is support for the use of continuous norepinephrine infusion over epinephrine to treat shock after ROSC, due to concerns about increased myocardial oxygen demand and associations with higher rates of rearrest [1,2] and mortality [2,3] with the use of epinephrine compared to norepinephrine, and increased refractory shock with use of epinephrine infusion after acute MI [4].
An article in this month’s AJEM compared norepinephrine and epinephrine infusions to treat shock in the first 6 hours post-ROSC in OHCA [5]. With a study population of 221 patients, they found no difference in the primary outcome of incidence of tachyarrhythmias, but did find that in-hospital mortality and rearrest rates were higher in the epinephrine group.
Bottom Line: Absent definitive evidence, norepinephrine should probably be the first pressor you reach for to manage post-arrest shock, especially if there is strong suspicion for acute myocardial infarction.
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This was a database study of nearly 2 million trauma patients over age 65 who were discharged looking at all levels of trauma centers. The authors found:
“Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White(1.9%), proportion female (1.5%), and urban/rural setting (1.4%).”
Level one centers had the lowest level of discharge to hospice. The authors felt: “As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.”
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This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!
Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset
This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.
It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)
Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.
Ramadan Kareem
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The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube. There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year. In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].
This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years. The individual optimal ETT insertion depth was plotted against age, weight and height for all children. This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas. Calculations using the patients’ weight performed the worst. Age based and height formulas performed the best.
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MYTH: Bactrim cannot be used as monotherapy for nonpurulent skin and soft tissue infections.
Not True!
Organisms of concern: Streptococcus spp.
Here’s why:
- Sulfamethoxazole-Trimethoprim (Bactrim) disrupts folic acid synthesis & utilization.
- This prevents the biosynthesis of the nucleic acid thymidine by bacteria and causes them to die.
- Some species of Strep, including S. pyogenes, are able to utilize exogenous sources of thymidine to continue their life cycle.
- Guess what? The laboratory media that was originally used to test Strep spp. susceptibility to Bactrim contained thymidine - therefore the bacteria were able to use it and did not die!
- When tested using thymidine-depleted media, all 370 S. pyogenes isolates tested were highly susceptible to Bactrim!
TRUTH: Bactrim CAN be used as monotherapy for nonpurulent skin and soft tissue infections.
Prepared by Rianna Fedora, PharmD on 2/26/24
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Background: There is no clear guidelines regarding whether norepinephrine or epinephrine would be the preferred agent to maintain hemodynamic stability after cardiac arrest. In recent years, there has been more opinions about the use of norepinephrine in this situation.
Settings: retrospective multi-site cohort study of adult patients who presented to emergency departments at Mayo Clinic hospitals in Minnesota, Florida, Arizona with out-of-hospital-cardiac arrest (OHCA). Study period was May 5th, 2018, to January 31st, 2022
Participants: 18 years of age and older
Outcome measurement: tachycardia, rate of re-arrest during hospitalization, in-hospital mortality.
Multivariate logistic regressions were performed.
Study Results:
- The study included 221 patients, 151 patients received norepinephrine infusion vs. 70 patients received epinephrine infusion.
- The maximum dose of epinephrine = 0.28 mcg/kg/min vs. 0.15 mcg/kg/min for norepinephrine.
- The Odds for clinically significant tachyarrhythmia was the same between both groups (OR 1.34, 95% CI 0.6802.62, P=0.40).
- Epinephrine infusion was associated with higher odds of in-hospital mortality (OR 6.21, 95% CI 2.37–16.25, P <0.001)
- Epinephrine infusion was associated with higher odds of re-arrest ( OR 5.77, 95% CI 2.74–12.18, P < 0.001)
Discussion:
It was retrospective study that uses electronic health records. Thus, other important factors from the pre-hospital settings might not be accurate.
On the other hand, the patient population came from multiple hospitals with varying practices so the patient population is more generalizable.
Conclusion:
Although the rate of tachyarrhythmia was not different between patients receiving norepinephrine vs. epinephrine after ROSC. This study would add more data to the current literature that norepinephrine might be more beneficial for patients with post-cardiac arrest shock.
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What happens if you have a patient who steps on a nail? How can you make this procedure easier for you and the patient?
– Use a Posterior Tibial Nerve Block! !
To Perform This Procedure:
- Have the patient lay on a stretcher and externally rotate their hip and have their knee flexed.
- Clean the area
- Use a linear probe with a sterile probe cover on
- Place the probe with the marker towards the patient’s right, just above the medial malleolus and positioned posteriorly.
- Identify the posterior tibial nerve next to the posterior tibial artery and center the probe on the nerve
- Use a 22–30-gauge needle in an out of plane technique, slowly inject about 5 cc of anesthetic, making sure you are just above the nerve and not in the artery.
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This secondary analysis of the NEXUS head injury data found patients over 65:
-sustained more significant injuries than younger pts
-presented more frequently with occult injuries
-when they required neurosurgery intervention only 16% went home, 32% were discharged to rehab facility and 41% died
-mechanism of injury was most commonly fall from standing
-mortality rates were highest for fall from ladder and auto vs. pedestrian injuries
The authors concluded: “Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.”
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Acetaminophen and low back pain.
Acetaminophen has been a traditionally recommended first line intervention for acute low back pain.
Cochrane reviews in 2016 and 2023 found that acetaminophen showed no benefit compared to placebo in patients with acute low back pain.
A 2020 study investigated whether the addition of acetaminophen to short term NSAID therapy was beneficial.
A randomized double-blind study conducted in two urban emergency departments.
Patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo.
Population: patients presenting with acute, non-radicular, non-traumatic lower back pain of fewer than two weeks duration.
Authors compared pain and functional outcomes at one week following discharge.
Conclusion: there was no outcome benefit from the addition of acetaminophen to ibuprofen.
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This is a retrospective study looking at traumatic brain injury patients comparing those with and without pre-existing psychiatric illness at the time of injury. Those with pre-existing illness had longer hospital stays, longer ICU stays and more frequent readmissions.
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This classic article should be on everyone’s reading list.
The Bottom Line: Clinicians engaging in metacognition, that is thinking about our reasoning process, can avoid making some critical errors and falling victim to cognitive biases.
Diagnostic errors are common in clinical medicine and particularly common in situations in which the clinician is faced with a novel circumstance and cannot, therefore easily apply heuristics or rules. There are also certain classic situations in which cognitive errors often occur (e.g., mistaking intracranial injury for intoxication). Through a process of active consideration of one’s diagnostic approach, many errors and cognitive biases (particularly availability bias and anchoring bias) can be avoided.
Take-home message: This article is worth reading in its entirety. Applying these principles can protect both patients and clinicians from the consequences of diagnostic errors.
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You've heard of one kill pills such as calcium channel blockers, beta blockers, sulfonylureas, anti-malarials, but less commonly known is benzonatate, or tessalon perles.
Tessalon perles are not recommended for children under the age of 10. 1-2 capsules of benzonatate in children <2 years old have been reported to cause serious side effects including restlessness, tremors, convulsions, coma and even cardiac arrest rapidly after ingestion (within 15-20 minutes and death within a couple of hours). It is attractive to young children as it somewhat resembles a jelly bean.
Pearls on Tessalon Perles:
- Always ask your patients about children in their household and strongly consider alternative to tessalon perles if children <10 years in home
- If you do decide to prescribe, prescribe only the amount of tessalon perles that a patient needs for cough relief
- Inform your patients about this high risk of accidental ingestion by children
- Keep tessalon perles in child-resistant container and keep it out of reach of children AT ALL TIMES
- Call the poison center (800-222-1222) immediately if accidental ingestion by child
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This meta analysis did not find convincing evidence for or against seizure prophylaxis for admitted moderate to severe traumatic brain injury pts. They recommend Levetiracetam over other medications again on weak evidence.
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The relationship between an Emergency Physician and the hiring group (whether large or small) may be one of employer-employee or contactor-independent contractor. There are legal job protections for employees that don’t exist for independent contractors. There are also regulations that define an independent contractor. Enforcement of these regulations varies but may be increasing. This has implications for the Emergency Medicine job market. We have the highest percentage of independent contractors of any medical specialty.
See more at Leon Adelman’s Emergency Medicine Workforce Newsletter, here https://emworkforce.substack.com/p/thousands-of-employed-emergency-physicians
Evidence is mounting that individuals with active or past history of cancer are at increased risk for acute cardiovascular events such as as acute myocardial infarction. This secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study- a multicenter, international, prospective diagnostic study looked at the prevalence of MI in patients with history of cancer presenting to the ED with acute chest pain, diagnostic accuracy of high-sensitivity troponins and diagnostic algorithms (European Society of Cardiology algorithm- see paper for details), among a few other parameters.
Take home points:
- There was substantially higher prevalence of AMI in patients with cancer.
- The diagnostic performance of the high-sensitivity troponin algorithms was reduced.
Translation to practice:
Be more conservative with cancer patients presenting to the ED with acute chest pain!