"My BP went from 160 to 170. Should I take an extra dose of my clonidine? or my metoprolol? or my enalapril?"
"No. You should stop checking your BP unless you have symptoms."
"Which should I take then?"
|There he is.|
Costochondritis was identified by digital palpation, applying enough pressure to induce partial blanching of the examining finger (=4 kg/cm2), over the costochondral and costostemaljoints (CCSJ), as previously reported. Patients were asked if such a maneuver: (1) caused no pain, (2) caused a pain different from original chest pain, or (3) caused a pain similar to the original one. Patients were considered to have CC if the answer was (2) or (3). The rest was used as a control group. Not included in this study were patients whose chest pain was associated with recent trauma, surgery, infection, fever, or malignancy.
How hard were these Rheumatologists pushing?**For features from the HPI that make ACS more likely, see Salim Rezaie's great summary in Academic Life in EM.
@mdaware @mgkatz036 Who has ever seen a Rheum in an ED, and why were they seeing CP pts?
— Cynic (@Apathetic_Cynic) March 29, 2013
One of the most interesting observations in this study was the low frequency ofAMI in the CC group, which was four times lower than in the control group, in spite of having similar risk factors for CAD, based on age, history of smoking, and hypertension.
The patient has crackophrenia hair.
|The patient has neck & face tattoos|
Why not just try to intubate these patients? If they desat or the airway is unexpectedly difficult, then place an EGA and reoxygenate.To me, the patient who needs RSA is the patient who you need to intubate now (no time for awake or AFOI or OR), and while you can preoxygenate, that preoxygenation is tenuous. This is admittedly a very, very small group of patients (smaller than the small group of patients who require DSI).
“It's not about plastic in the trachea, it's about oxygen in the lungs." (Rich Levitan)Sure, there is a risk for aspiration. But if the patient is desaturating precipitously, then the risk for hypoxia is much higher than it usually is. Here RSA is used to avoid hypoxia -- which you know will be a problem, while aspiration only might be a problem.
“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.ACEP had considered joining 3 times before, but was concerned that and most recently had declined to join in the summer of 2012. Some concerns expressed by then-ACEP president David Seaberg include:
Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered
It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.
it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.Although those concerns are not unwarranted (mostly the latter 2), I think they are generally outweighed by the benefits. As I explained in a reply on the EP Monthly re-post of the same essay by Dr. Seaberg:
Choosing Wisely is gaining national recognition for its patient-centered approach to decreasing unnecessary care. This is one major way we -- as professionals -- can decide what is appropriate for our patients. Parsimony is coming. If we don't take the lead then others will decide how we should care for our patients. As a specialty, we can define our standard of care so groups like CMS don't have to.