October 3, 2019

Life and work can serve up its fair share of adversity and setbacks that we have to contend with. In medicine we are often tasked to perform under time pressures to do complex procedures, deal with human suffering, and make decisions where life/death hang in the balance of our actions or inactions. Adversity has the power to create newfound strength, possibilities, and understanding if we can navigate through them effectively. Conversely, adversity can also destroy our passion, our self-confidence, and what is possible if we do not navigate through them effectively.  In this 20 minute talk from Rebellion in EM 2019, Jason Brooks talks about how adversity in and of itself does not lead to value, but it’s what we do with these adverse experiences that matter the most.

September 30, 2019

Background: Chest pain is a common chief complaint the Emergency Department, and the differential diagnosis includes life-threatening conditions from several organ systems including cardiac, pulmonary, and gastrointestinal, in addition to more benign etiologies. Historically, despite most patients not having acute coronary syndrome, there is still a high rate of medical admissions in patients with chest pain. The advent of accelerated diagnostic protocols has aided in guiding clinicians with decision making and disposition of these patients. This study aimed to address the question of whether or not an emergency medicine physician’s clinical gestalt would be sufficient to rule in or rule out acute coronary syndrome (ACS). Several studies have addressed this question with conflicting results. Given the high morbidity and mortality of acute coronary syndrome, emergency medicine physicians focus their clinical decision making on decreasing type II errors, i.e., false negatives. In clinical practice, this means having a low rule-out rate based on physician gestalt; in other words, most patients with chest pain presenting to the Emergency Department will have testing including an EKG and troponin level even for patients for whom the physicians have a low clinical suspicion for ACS.

September 26, 2019

Background Information: Critical care and emergency medicine are frequently intertwined as the resuscitation of critically ill patients occurs in both environments. While the majority of these patients come through the emergency department (ED), the resuscitation of critically ill patients is not defined by a geographic location, but rather a set of principles designed to deliver appropriate care in a timely fashion.1,2 Increased numbers of critically ill patients in combination with decreased availability of intensive care unit (ICU) beds and a shortage of intensivists has led to a shift in critical care being delivered in the ED.3 Furthermore the lack of ICU beds, among many other factors, have contributed to a prolonged length of stay (LOS) of already admitted patients known as “ED Boarding”. Another factor to consider, is that providing prolonged critical care in a traditional ED setting is challenging as it requires more staff and is often associated with increased mortality. Multiple studies have demonstrated an association of worsened outcomes when patient’s ED LOS is greater than 6 hours and, in the United States, 33% of all ICU admissions from the ED have an ED LOS greater than 6 hours.1,4 A proposed solution has been the development of ICUs housed within the ED known as ED-ICUs. While only a handful exist, this new method of care delivery aims to reduce the time it takes for patients to receive critical care and offset the strain on current ICUs (Table 1)4. The authors of this study sought to determine the association of ED-ICUs on 30-day mortality and inpatient ICU admission.

September 25, 2019

Take Home Points
  • When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications. 
  • LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
  • Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
  • Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
  • Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia. 

September 23, 2019

Background: Supraventricular tachycardia (SVT) is not an uncommon condition in the emergency department. Epidemiologically, SVT has an incidence of 35/100,000 person-years in the United States.2That is roughly 89,000 new cases per year. The Valsalva maneuver is a recognized treatment for SVT, but has a low success rate (5-20%). 3,4,5 The REVERT trial showed an increase in cardioversion of SVT using a modified Valsalva maneuver, but this was done with a manometer, and adjustable bed, which may not be available in many settings.