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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

July 30, 2012

More MDA on PHARM: Airways & Human Factors

Minh Le Cong interviewed me on:
  • A little bit on why I'm doing health policy
  • Transition from resident to attending
  • Not torturing intubated patients
  • Critical airway case discussion
  • My first intubation as attending
  • Human factors tips for airway & team management
  • My love for ETCO2
  • A little rehash of our cricoid pressure debate

Thanks Minh!

July 27, 2012

3 Simple Rules to Avoid Torture

Don't do this.
Scott Weingart has another great but unfortunately sad post about post-intubation sedation.

The fact that this needs to be discussed at all makes me sad, which inspired me to share some pearls.

Not sure which of these I learned from Scott Weingart specifically (most likely: all of them). Special thanks to Scott for teaching me to fix patients without torturing them.

(nb - I'm going to use the terms "sedation" and "sedative" even though the first line should be analgesia. see EMCrit 21)

Here are 3 simple things that I do to not torture my patient:

1. Sedation is an RSI med

Ask for your sedative the same time you ask for your RSI meds.

If you're planning on intubating a patient, it should be no surprise to you that very soon you will have an intubated patient that requires sedation.

This is easy.

Sample interaction:

"Can you please get me 100 mg of roc, 100 mg of ketamine, and a fentanyl drip?"

2. Paralysis is NOT sedation

Just because your patient is sitting there calmly does not mean they are comfortable, particularly if you have given them a paralytic. This is relevant in 2 ways.

a) If you used roc to intubate, your patient is paralyzed for some time, so remember to sedate them.

b) Don't use paralytics as post-intubation sedation.

"10 of vec" is NOT a sedative. Don't use it. Forget that it exists. It makes your life easier but is unequivocally terrible.

I won't say "never" because there are a few RARE circumstances where paralysis may be necessary in the intubated patient. Namely, this is at the very end of the algorithm for the ultra-severe asthmatic, and certain special circumstances of ventilator-dyssynchrony. But in both of these cases, your patient should be sedated FIRST and DURING paralysis.

If you're not really sure what I'm talking about here (and even if you are) then make sure you talk to an intensivist before you use paralytics here; or (more likely): NEVER use paralytics for the already-intubated patient.

3. Don't use pain as a pressor

see: EMCrit - Pain and Terror as Effective Pressors

The ETT comes with sedative, period. Treat the blood pressure as you would anyone else -- resuscitate, add pressors, or dial down PEEP (you actually have one more option than in the non-intubated patient).

2 options to maintain MAP in the hypotensive intubated patient:

a) no pressor, no sedative, yes torture

b) yes pressor, yes sedative, no torture

If you're not sure which of these is a better idea then... well I don't have a polite way to end this sentence.

July 17, 2012

Residents: Please Read

This is adapted from an email I sent to the incoming EM residents as I graduated a few weeks ago. Of course, no monetary conflicts of interests of any kind, and these recommendations are just personal tips (and see also):

As outgoing academic chief, one thing I cannot stress enough is that you really need to read during residency.

You cannot just show up for shifts.

You need to do more than listen to EMCrit, and all of the other great sites like Life in the Fast Lane, ERCAST, PHARM, SMARTEM, etc. (I know I left a lot of great sources out -- there are too many to name). Not that you shouldn't read or listen to this stuff, but recognize that the topics covered are generally things that are sexy: interesting, controversial, or very practical or technical tips & tricks. But those are all different than a core curriculum.

And while you should listen to EMCrit etc., that sort of clinical information is not sufficient for board prep nor for core topics, especially the tough/less popular ones that are over-represented on the boards and under-represented in our patients (and nobody likes) like ophtho, derm, and even bread & butter simple illnesses like gastroenteritis.

Other than reading a textbook (which I wish I had done much more of), top things I think you can do to be both a better doctor & better board prepped: the idea should be to focus on building a foundation of core content, without getting completely distracted by the some of the more fun bells & whistles out there. There are lots of places to find great EM core content curricula; here are some examples: 

EM:RAP -- probably the best "core topic" podcast. It comes free with a resident EMRA membership. Worth figuring out how to download. They cover major topics, and last year introduced their "C3" project where they review core topics for board prep.

Read Annals of Emergency Medicine. Every month. You don't need to read it cover to cover, but at least browse through the abstracts & editor reviews. I will admit that at first it seems to cover obscure topics, but after reading for a few months I realized that something relevant from a recent Annals came up every single shift. Articles are picked by the leaders in our specialty, and they're quite good at it. I keep mine in the bathroom and slowly get through it.

Emergency Medical Abstracts -- also free with resident EMRA. great podcast that started in the late 1970s (they used to mail out cassette tapes) by Rick Bukata & Jerry Hoffman (who is probably the most worthwhile EM figure out there). They go through 30 abstracts from recent journals of all stripes, all relevant, and discuss each one for 2-10 minutes, which includes a lot of banter on the topic. A lot of people are put off by the (brief) methodology discussion of each paper but I promise it's worthwhile.

Some others: Life in the Fast Lane and EM Basic both have plenty of excellent free core content.

Also: get on national committees. EMRA, ACEP, etc. Easy to get on, little work with huge reward, and most are just a matter of signing up.

Last tips: 
  1. be nice to everyone (it pays off)
  2. do what's best for the patient (not only is it the right thing to do but you get to win more fights)
  3. and remember: as Jerry Hoffman says: we have the best job in the world, and as Mel Herbert says, what we do, matters 

And please read.

July 11, 2012

Some IO Pearls

There's been some online chatter about IOs recently, and that got me thinking about a lot of the pearls I have picked up.

Some background: I think we should probably do more IOs, particularly on the non-sick patients. Ever placed a triple-lumen CVC on a patient just because you couldn't get an IV even with an ultrasound? That patient should get an IO instead. Fewer complications, easier & faster to place. My theory is that while drilling into bone is painful, that lasts a second or less, and poking around in a healthyish patient to place a TLC has to be worse.

Complications do happen, but if you do IOs right, the complication rate is low.

This is not a comprehensive list of everything you need to know before you IO. Just some tips that make IOs easier & safer.

n.b. this mostly assumes a powered device, such as the EZ-IO*

IO Pearls:

Placement should just feel right
It's hard to describe but the tactile sensation when you drill in just feels right (or wrong) as you get through the cortex into the medulla.

Spin before the skin
Otherwise, the skin gets all caught up in the spinning bit.

One shot per bone
The main danger of IO is extravasation (leading to soft tissue damage), and no matter how poor your first attempt, you probably popped a hole in the cortex. If you then place a working IO, it will leak out that hole, and badness will ensue.

BM is great but not necessary
Successful aspiration of a small amount of bone marrow "confirms" placement but is not 100% sensitive (NPV is poor); even if aspiration doesn't work, you should try flushing. Pay close attention to any sign of leak (and monitor those compartments...) -- maybe ultrasound is useful for checking for leaks? (I have no idea; someone should look into that).

Put in a 2 ml or so of lidocaine to numb up the marrow. This could hurt. Consider repeating if using for a while. Check your lido dosing as this is pretty much IV lidocaine.

Flush 10-20ml
This "primes" the marrow to allow for better infusion rates.

The big bad thing that can happen with an IO is compartment syndrome. Make sure this is checked, especially since most IO patients won't be able to complain of searing calf pain. You don't want to revive the arrested patient only to make his leg fall off.

24 hour limit
IOs should be removed as soon as possible (i.e. after alternate access achieved) but should be taken out before a full day.

To remove: pull STRAIGHT out
You can twist even though they're not threaded but...

Do NOT rock on removal
Rocking evidently causes bone cracks and kills puppies. Big no-no.

Tips from Matt:

The stylet is the worst sharp
The stylet from the IO needle is basically the sharpest needle in the world, with teeth. BE CAREFUL.

Lido isn't perfect
Understand that even after infusion of lido, injection is going to be very painful. May be difficult to use in a patient you were going to keep awake.

Pressors are OK 
Remember that IO is relatively safe for pressors, probably better than a bad peripheral.
"I have had a few residents ask me about sternal IOs, these are military items meant to be placed with no drill. They are a paddle like mechanism and are designed so that body armor can be opened and the IO can be placed. EZ IO drills are not for sternums under any circumstances. Does not seem like something that would need stating but I've been asked multiple times."
How-to Video:

This video is from Dena Asaad Reiter's excellent EMProcedures page:

*I don't get money from them (really)