May 25, 2020

“You’re working a shift in whatever the lower acuity version is of your department. So maybe it’s fast track, maybe you call it an urgent care. Whatever it is, it’s a unit where they take doctors, who trained for 7 or 8 years to become expert resuscitationists, and make us spend all day seeing sniffles, sore throats and chronic back pain in a manner that I can only assume was designed specifically to make us all exceptionally crazy. But, either way: that’s where you’re working. You’ve taken care of a young woman, you’ve treated her ailments, you’ve decided what’s wrong with her. And you’re deciding you are going to prescribe a few medications for her and send her on her way. You’ve answered all of her questions and you are walking out the door, your hand is on the door handle and she says “Oh, but doc, did I tell you I’m currently breastfeeding my 6-month old baby? Can I even take these medications?” And your heart stops. And you freeze. And your hand is still on the door handle. And the first thought that goes through your head is “Oh my God, I have no idea.” Because you, like most of us, had one lecture on medications in pregnancy and lactation back in your second year of medical school and you have no idea what you learned. That’s your first thought. “Oh my god, I have no idea.” Your second thought is “Oh my god, I have 8 more patients that just got triaged, while I had that thought. What am I gonna do?” Your third thought then is that you breathe a sigh of relief and you go “It’s ok, I’ve got an ED pharmacist. I’ll just ask her.” But then you’re horrified again because you realized it’s Saturday! And while you work in a 24/7/365 emergency department, your department has decided to staff this one crucial member for just business hours from Monday through Friday. And you think “That’s terrible.” And now you’re back to horror. Because, again, you don’t know what to do. And another 8 patients have been triaged and they all have chronic back pain and they’re asking why they haven’t been seen yet. And you’re still in that room and your hand is still on the door. Now you think “I don’t know. I don’t know.” “Honestly lady, I don’t know, you probably should just pump and dump.” Out of an abundance of caution we always just revert back to “You should pump and dump.” But I’m going to argue that that’s probably not the best strategy.”

May 24, 2020

This publication has now been retracted by Lancet (June 4, 2020) Background: There is no conclusive evidence that chloroquine, or its derivative hydroxychloroquine, with or without a second-generation macrolide is effective in COVID-19 treatment or prophylaxis. Laboratory studies have shown antiviral and immunomodulatory properties in vitro. The small retrospective observational trials thus far have had mixed results in efficacy.  However, these medications are well known to have cardiovascular adverse effects via QT interval prolongation leading to ventricular arrhythmias. Despite the potential harms and the absence of convincing data to support treatment with these drugs, they are widely prescribed to COVID-19 patients.

May 23, 2020

Disclaimer: This post explores some of the pathophysiologic findings in severe SARS-CoV-2 infection. It explores possible mechanisms-based and posits theories BUT, this is not a clinical post. The hypothesis and findings here are not confirmed and extrapolation to management is unclear. Understanding of the mechanisms of COVID-19 is badly needed if we are to find treatments that may be beneficial. The leading cause of mortality in patients with COVID-19 is hypoxemic respiratory failure most frequently resulting in ARDS.  However, the mechanisms that bring patients from infection to ARDS are unknown:  is it diffuse alveolar damage (DAD), endothelial damage, or some combination of both? Although it may seem ridiculous to consider these two entities as separate, as the alveolar-capillary interface is submicrons in size, we want to know if one of these two entities is driving the injury more than the other? There have been some interesting pathological reports that have been published looking at the histopathology of COVID-19, and many more discussions about the similarities to other viral pneumonias (i.e. H1N1). A recent publication in NEJM compares the pathology of COVID-19 vs H1N1.

May 21, 2020

Background: Upper endoscopy allows for the identification of the source of bleeding as well as hemostatic treatment for actively bleeding lesions In patients with upper gastrointestinal bleeding (UGIB).  Definitive treatment with endoscopic hemostatic treatment can potentially stop bleeding in high-risk lesions and reduce further bleeding and the need for surgery. The optimal time for endoscopy to be performed is unknown.  The definition of urgent varies depending on which study you read, ranging from 2 hours up to 12 hours. Additionally, most previous studies only enrolled patients who were not hemodynamically unstable or high-risk, which is frequently what we are dealing with in the emergency department. The Glasgow-Blatchford score is a validated risk-assessment score for the prediction of clinical outcomes, including the need for intervention and risk of death.  The score ranges from 0 to 23, with higher scores indicting a higher risk of further bleeding or death. A threshold score of ≥7 has been shown to be the most accurate predictor of whether a patient will need endoscopic treatment.2 There are conflicting results regarding urgent endoscopy (within 6 hours after admission) and mortality.

May 19, 2020

While the rate of prepublications on COVID19 continue to be cranked out, we at REBEL EM have reduced our blog post production. It’s not because we’re reading less, but  we’ve reported enough on small, retrospective, observational studies that don’t tell us anything more than we already know.  At this point in time we know enough about what does and doesn’t work, so we wanted to focus on important literature that may affect practice. Going forward that will be our focus with updates in a less rapid-fire rate and more useful way to digest the information. For this COVID-19 update we have picked four papers that are we thought are worthy of mention.
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