Wednesday, September 18, 2019

Tips for Pumping While Working in the Emergency Department

This post is a bit different than the typical evidence-based post. Rather than a post on how to take care of patients, it's a compilation of tips for expressing breastmilk while working in the Emergency Department

Why is this important?

This is an important issue for everyone, not just women and not only those who are breastfeeding. 
There are tangible ways everyone can contribute to a supportive atmosphere. This includes being supportive of colleagues and reaching out to those who are returning from leave. If your colleagues don't have a place to pump, join them in advocating for a space (by the way, a bathroom is NOT an appropriate place to pump). Know that residents may be especially reticent to ask for time to pump due to being perceived as "weak" or "lazy." 
Pumping on shift can be stressful and come with guilt for stepping away from immediate patient care. There are things that you can do to minimize the time away. 

 Pumping in the car (or on a commute) can be a game changer to ensure you start the shift at time 0, effectively resetting the clock until your next pump.

Pumping on a single coverage shift may seem impossible but it is do-able. One of the most important things is discussing this with your team. Some techs and RNs may feel comfortable coming to you with ECGs or patient updates while pumping, others may prefer to call. Establish a game plan ahead of time.

Know that being able to pump at work is a legal right in the United States and that the American College of Emergency Physicians (ACEP) released a statement in 2013 supporting workplace support for lactating clinicians. 

Saturday, March 23, 2019

Risk Adjusted Dimer in the Workup of Pulmonary Embolism in Pregnancy

The Gist: Use of the YEARS algorithm in pregnant patients with possible pulmonary embolism (PE) appears safe and results in fewer computed tomographic pulmonary angiograms (CTPAs), particularly in low-prevalence testing environments [1]. Given the natural course of d-dimer throughout pregnancy, gestation adjusted versions of this algorithm may better curb overtesting.

The workup of pregnant patients for suspected pulmonary embolism is challenging for some of the following reasons:

  1. Risk of ionizing radiation to the fetus.
  2. Risk of ionizing radiation to maternal breast tissue.
  3. Hormones during pregnancy thought to place pregnant patients at higher risk for venous thromboembolism.
  4. The d-dimer is known to increase throughout pregnancy making this test difficult to interpret or useless based on one's approach. A study by Murphy et al found a steady rise in median d-dimer values in healthy pregnant patients throughout pregnancy. This group found that the median d-dimer in pregnant patients crossed the threshold for non-pregnant patients prior to 20 weeks of gestation [2].
Researchers are tackling this issue with various algorithms. In October 2018, Righini and colleagues published an algorithm rooted in the Geneva Score which would have resulted in fewer CTs. Now, van der Pol and colleagues have published the results of using the YEARS algorithm in pregnant patients. The article is summarized below but briefly, this protocol was implemented in ED and OB units at several centers in Europe and patients were followed up. The results demonstrated safety in this population with overall low prevalance of PE (4% overall).

YEARS in Pregnancy Study Protocol

Notably, a standard YEARS approach to testing for PE in the pregnant patient results in imaging many patients for PE who do not have the disease in question due to the standard trajectory of d-dimer in a healthy pregnant patient. Additionally, the YEARS criteria represent a modified Wells criteria with the most commonly positive criteria being "PE is the most likely diagnosis." Many providers find this criterion frustrating. Future approaches may examine the effects of a gestation adjusted version of the YEARS algorithm. Yet, in the era of overtesting for PE in pregnant patients, use of this algorithm may reduce imaging in these patients.

1. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 019;380(12):1139–49. 1. 
2. Murphy N, Broadhurst D, Khashan A, Gilligan O, Kenny L, O ’donoghue K. Gestation-specific D-dimer reference ranges: a cross-sectional study. BJOG. 2015;122:395–400. 
3. Righini M, Robert-ebadi H, Elias A, Sanchez O, Moigne E Le. Diagnosis of Pulmonary Embolism During Pregnancy. Annals of Internal Medicine. 2018;
4. Kline J a, Richardson DM, Than MP, Penaloza A, Roy P-M. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014;21(9):949–59. 

Thursday, March 7, 2019

Slaying Pre-historic Practice: Epinephrine in OHCA

The Gist: For nearly 15 years, the American Heart Association (AHA) Guidelines have stated epinephrine in out of hospital cardiac arrest (OHCA) is reasonable, not that it is standard of care to administer epinephrine routinely [1-3]. A large randomized controlled trial recently confirmed that while epinephrine increases the return of spontaneous circulation (ROSC), it may do so at the expense of a good neurologic outcome [4]. We likely believe we should administer epinephrine routinely because of difficulties unlearning low-value practices.

Administration of epinephrine 1mg every 3-5 minutes is ubiquitous in OHCA. In fact, the pocket algorithm card included in the AHA guidelines merely lists "Epinephrine q 3-5 minutes." The AHA guidelines, however, give epinephrine a relatively low-level recommendation (Class IIb) and merely state it is "reasonable to consider" using epinephrine in OHCA.

A recent randomized controlled trial, the PARAMEDIC-2 trial, is the largest trial comparing epinephrine with placebo in OHCA. This trial brought renewed attention to the debate as to whether to administer epinephrine routinely in OHCA as patients survived more frequently with epinephrine but did not achieve better neurologically favorable survival [4]. The study was not powered to detect differences in neurologic survival, which may be difficult to do given the low numbers with a favorable outcome; however, does demonstrate this continued trend toward reviving the heart at the expense of the brain.

Why do we have a difficult time unlearning that epinephrine is "standard of care" in OHCA?
We rarely read the guidelines in depth.
The pocket algorithm card lists "Epinephrine q 3-5 minutes" and does not go into details about the risks and benefits of epinephrine administration. Guidelines are often long, cumbersome and difficult to read so we rely upon the synopses provided in simplified algorithms or on the simplified distillation by others.
It's harder to unlearn NOT to do something than it is to add something to our repertoire.
Many of us have a bias towards action, particularly in resuscitation. We want to save patients, we want to do whatever we can.  In OHCA, survival is poor with a mere 2-10% survival and often depends on shockable rhythm, etiology, and defibrillation [4,5]. Epinephrine may give us the satisfaction of feeling as though we are doing something in a typically futile situation.
We may be less likely to fear the consequences when they aren't proximate to our intervention.
We often don't see the downstream consequences that happen after achievement of ROSC in the emergency department - including poor neurologic function.

1. ILCOR. Part 4: Adult Cardiac Life Support. Circulation. 2005 Nov 28;112(24_suppl). Available from:
2. Neumar RW, Callaway CW, Sinz E, Davis D, Otto CW, McNally B, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18_suppl_3):S729–67. 
3. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18):S444–64. 
4.  Perkins G, Ji C, Deakin C, Quinn T, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018; 
5. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018; 137(12)

Friday, November 2, 2018

Droperidol vs ondansetron vs placebo for nausea

The Gist: In the United States, droperidol has been hard to come by in many locations for years. Many lament the loss for a myriad of indications - agitated delirium, nausea, vomiting, and migraines.  Meek et al found that in nauseated emergency department (ED) patients, droperidol 1.25 mg IV did not outperform ondansetron 8 mg IV or placebo IV in a randomized, blinded trial in 3 Australian EDs [1]. Common anti-emetics or placebo, reduce nausea scores by similar amounts; however, more patients receiving ondansetron or droperidol reached the desired effect and did not receive rescue medications.

Nausea is a common condition in the emergency department; yet ED-based studies of anti-emetics have not found consistent benefit [2-5]. Droperidol received a controversial black box warning in the US in 2001 after 71 adverse events were reported on a single day. Since that time, many providers have lamented to lack of availability of droperidol in the US and thought...this would be the clear winner for our nauseated patients. Hence Meek and colleagues aimed to settle the debate as to whether any of these drugs were superior to placebo in nauseated ED patients. Details pictured below.

Unfortunately, this trial leaves several questions unanswered. It's not all bad news in anti-emetic therapy. Recent trials of inhaled isopropyl alcohol have been promising and this intervention appears to be more effective than oral ondansetron alone [6,7]. It's uncertain how long these effects last and how this therapy would perform compared with intravenous therapies.

  1. Meek R, Mee MJ, Egerton-Warburton D, et al. Randomized placebo-controlled trial of droperidol and ondansetron for adult emergency department patients with nausea. Acad Emerg Med. 2018;In Press. doi: 10.1111/acem.13650 
  2. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med 2006; 24: 177–82. 
  3. Barrett TW, DiPersio DM, Jenkins CA et al. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults. Am J Emerg Med 2011; 29: 247– 55.
  4. Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med 2014; 64: 526–32.
  5. Furyk JS, Meek R, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting (Review). Cochrane Database Syst Rev 2015: CD010106. 
  6. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016;68(1):1-9.e1.
  7. April MD, Oliver JJ, Davis WT, et al. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med. 2018;

Wednesday, October 24, 2018

Pulmonary Embolism Workup in Pregnancy: Is D-dimer a Thing?

The Gist: D-dimer rises during pregnancy and few patients will have a normal d-dimer by the third trimester. However, integration of d-dimer into a diagnostic algorithm for pulmonary embolism (PE) could reduce the need for CT scan by ~11% [1]. The next step - gestational age adjusted d-dimers.

The workup of pregnant patients for PE is complicated. Pregnancy is considered a risk factor for PE. However, the algorithms and risk stratification tools widely used excluded pregnant patients in the development phase. Additionally, the use of the d-dimer in pregnancy is controversial in pregnancy. It's known that the d-dimer rises through pregnancy, making the utility questionable. While some have attempted to determine gestational age adjusted d-dimer cut offs and one expert recommends a first trimester cutoff of 750 ng/mL, a second trimester, cutoff of 1000 ng/mL, and a third trimester cut off of 1250 ng/mL, this has not been formally studied in PE[2,3]. Further, the risks of the objective tests in the patients may be greater due to radiation to the fetus and maternal breast tissue.

A group in Switzerland (also the creators of the Geneva Score) tested an algorithm on nearly 400 patients which appears promising. See algorithm and study summary below. Further research will be needed to ascertain if an elevated dimer cut-off based on gestational week can be used and if another risk stratification tool performs better in this population. For example, the Revised Geneva has age >65, which is essentially incompatible with pregnancy as well as heart rate cut offs of >75 or >95 beats per minute, when the average heart rate in pregnancy rises to >90 beats per minute.

1. Righini M et al. Diagnosis of Pulmonary Embolism During Pregnancy. Ann Internal Med. 2018; In press. doi: 10.7326/M18-1670
2. Murphy N, Broadhurst D, Khashan A, Gilligan O, Kenny L, O ’donoghue K. Gestation-specific D-dimer reference ranges: a cross-sectional study. BJOG . 2015;122:395–400. 
3. Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015;49(1):104-17.

Wednesday, August 1, 2018

Breastfeeding and Alcohol: A sensational but flawed study in Pediatrics

The Gist: A recent study by Gibson et al in Pediatrics claims to show a link between cognitive delays and alcohol intake while breastfeeding [1]. Despite wild uptake by lay and medical news outlets, this study is seriously flawed by confounding, multiple comparisons, and inappropriate extrapolation of survey data. As a result, the study findings do not support this conclusion and do not support a causal link between drinking alcohol while breastfeeding and cognitive delays. Breastfeeding while inebriated may pose risks due to safely handling the baby and safe sleeping, but unlikely from the alcohol contained within the breastmilk in otherwise healthy term babies. Further, high-risk alcohol use (binge drinking, dependence) may be associated with other factors that could potentially influence the cognitive and emotional development of children. However, this study only shows our obsession with p values and statistical significance.

Gibson et al hypothesized that alcohol use during lactation would be associated with lower cognitive scores in children [1]. The lead author has said, "it suggests that there is no safe level of alcohol for a breastfeeding mother to drink" [2]. However, the study does not actually suggest this. An overview of the study can be found in the graphic above.

1. Misunderstanding the term breastfeeding
The authors inappropriately describe "drinking while breastfeeding." Consuming alcohol while lactating is not the same as drinking while breastfeeding, although it is unlikely that either have clinical significance in most scenarios. The questionnaire administered at Wave 1 asked about general current alcohol intake and whether or not the infant was breastfed (in general). They did not ask about the specific timing of drinking, not that this necessarily matters. Further, the authors did not measure alcohol concentration in the milk they were feeding their infants, which would really be the only way to demonstrate causation (which would be an impossible study to conduct, yet the authors used the word "cause" in the manuscript).

Alcohol intake during breastfeeding has been controversial as it is known that alcohol does transfer into breast milk [2]. Official recommendations are to refrain from drinking while breastfeeding or limit to 1 drink per day based on this notion [3]. However, the amount of alcohol an infant would ingest is minimal as the percentage of alcohol in the breastmilk approximates that of the mother's blood alcohol level (or approximately 5% of the intake) [2]. Further, milk production and composition is a dynamic process such that when an individual is no longer inebriated, the breastmilk does not contain alcohol [2]. As such consuming alcohol and directly feeding the baby at the time of peak ethanol effects is different than consuming alcohol at a time period when the mother is not feeding the baby (ex: immediately after nursing or at night).

2. Multiple comparisons
Only one transient, statistically significant association was found, as seen below. Children who were ever breastfed, the bulk of whom were not being breastfed at the time the alcohol questionnaire was administered (~age 9.7 months), with mothers who had scores associated with high or risky alcohol consumption performed less well on the Matrix Reasoning subtest of the Wechsler Intelligence Scale at Wave 4 (~age 7) but not Wave 5 (~age 10). The more comparisons, the greater likelihood of finding a positive association due to chance. While these authors did use the Benjamini and Hochberg procedure to control the false discovery rate (proportion of false positives), the bulk of the data including the vocabulary test and the early literacy/numeracy tests do not support this association.

3. Data dredging: p-value without clinical significance
Researchers have an obsession with p values. This study had greater than 99% power to detect a small effect size. Even with this power, the study did not detect an association in 6 of the 7 time-outcome combinations they evaluated. Yet,the authors focused on the single statistically significant association that was not found on follow up tests (i.e. a child whose mom had ever breastfed them and engaged in high/risky alcohol use at Wave 1 performed less well on the matrix reasoning test at Wave 4 but performed on par with peers at Wave 5). Additionally, if it were the alcohol that resulted in the lower scores, we would expect to see the same (or greater) results in infants who were currently being breastfed.

Even if this association was real rather than a statistical anomaly, the kids who were being breastfed at the time of the alcohol questionnaire had no measurable deleterious cognitive outcome at follow up.

4. Lack of an adequate control group and missing data. 
Just over 8% of infants were classified as "never breastfed." This is a tiny group with few expected outcomes. Additionally, this cohort had significant missing data, notably 17.2% missing data for alcohol consumption.

Most physicians lack significant training regarding the care of lactating patients and advice regarding "pumping and dumping" (pumping and discarding milk instead of feeding it to the baby) is rampant, even when medications are safe in lactating patients [3]. For example, as recently as 2017 major anesthesia texts recommended empiric "pumping and dumping" for 24 hours following anesthesia [4,5]. Studies such as the one by Gibson et al, which has been picked up by news outlets, only serve to increase fears without actually contributing meaningfully to the knowledge base [1]. It is time to move from the overly cautious approach to the lactating woman to a reasonable, evidence-based approach in order to support breastfeeding without creating hysteria amongst parents.


  1. Gibson L and Porter M. Drinking or Smoking While Breastfeeding and Later Cognition in Children. Pediatrics; In Press.
  2. Rapaport L. Drinking while breastfeeding tied to cognitive problems in young kids. July 31, 2018.
  3. Haastrup MB, Pottegård A, Damkier P. Alcohol and breastfeeding. Basic Clin Pharmacol Toxicol. 2014;114(2):168-73
  4. CDC. "Alcohol."
  5. Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk. Transl Perioper Pain Med. 2015;1(2):1-7
  6. Dodd SE, Sharpe EE. Pump and Dump; Anesthesiologists Lead the Feed. Anesthesiology. 2018;128(5):1046-1047.
  7. Wijeysundera D, Sweitzer BJMiller RDPreoperative Evaluation, Miller’s Anesthesia. 2015, pp 8th Edition. Edited by Elsevier, 1085–1155

Wednesday, September 13, 2017

Quarterly Literature Update - September 2017

Do abscesses need antibiotics after incision & drainage (I&D)
Two recent studies have rendered many with the conclusion that antibiotics improve cure and recurrence rates when added to I&D.  Talan et al randomized people with abscesses after I&D to TMP-SMX or placebo and found improved clinical cure rates in the TMP-SMX group (80.5% vs 73.6%). This year, Daum et al randomized patients to TMP-SMX, clindamycin, or placebo after I&D and specifically looked at small abscesses (<5 cm) and again found higher rates of 10-day clinical cure in patients receiving antibiotics (TMP-SMX 83.1%, Clindamycin 81.7%, Placebo 68.9%). Many people have pushed the idea that all abscesses need antibiotics after drainage based on these studies. However, these studies included patients with significant surrounding cellulitis (on average, >25 cm2) and most recommendations have historically recommended antibiotics to those with more than a 5 cm diameter of surrounding cellulitis
  • Bottom Line: After I&D of an abscess, give antibiotics if there is >5 cm diameter of surrounding cellulitis (~30 cm2 total).  We probably do not need to do this if less cellulitis.
  • Stats/Study Design point: With any study check out the baseline/demographics table and ask - are these patients like my patients.
FAST is fast, but is it good?
The FAST exam, initially developed to assess for free fluid in unstable trauma patients, is widely used and may be an area where indication creep (i.e. we start expanding the indication for it) has really taken hold. Holmes et al performed an RCT on 945 stable pediatric blunt trauma patients who were randomized to standard trauma evaluation + FAST or just a standard trauma evaluation. There was no difference in rates of CT scans (~50% in each arm), missed intra-abdominal injuries (n=1 in FAST arm), or hospital charges. Even things like length of stay and hospitalization rates were about the same between groups.
  • Bottom Line: Keep FASTing trauma patients who are unstable or borderline unstable and management may change based on the FAST results (i.e. thoracotomy or OR). Find a negative FAST on a trauma patient? That’s called a false sense of security.
  • Stats/Study Design point: Beware of indication creep (using a test in patients it was not originally designed or validated in - this can change parameters such as sensitivity and specificity)

A magic sepsis cocktail?
Marik et al have made a wave in public media for a magic sepsis cocktail of vitamin C, hydrocortisone, and thiamine. In this paper, they published their findings of a paltry 47 patients who underwent treatment and report an incredible mortality reduction in the cocktail arm (8.5 % 4/47 vs 40.4% 19/47). The primary author, very well respected in the sepsis/critical care community, has argued that this treatment should be adopted immediately because prior studies show biological plausibility. However, this is a supremely tiny hypothesis generating study subject to incredible bias (see this podcast) due to no blinding and other factors. Further, prior studies of individual components (ex: steroids) have been negative.
  • Bottom Line: Vitamin C, hydrocortisone, thiamine is an inexpensive and relatively benign therapy; however, a single retrospective study of 47 patients cannot inform us of efficacy or harm.  Medicine is rife with examples of adopting therapies too early because they look promising based on terrible studies only to later find out that they don’t work. Further studies will be needed to determine whether or not this practice should be adopted.
  • Stats/Study Design pearl: Before/after studies are subject to significant bias and confounding. In this study we worry about the lack of blinding as all providers and patients knew what they were getting and that there was this new "life saving" cocktail - perhaps this could have influenced other care.

Haloperidol HUGS and Love
Gastroparesis and cyclic vomiting patients are frustrating and often their medication allergy lists are extensive. Enter haloperidol, a butyrophenone antipsychotic (dopamine antagonist), a sister medication of droperidol. Roldan et al randomized 15 patients with gastroparesis to 5 mg IV haloperidol + conventional treatment and 18 patients to conventional treatment alone. Pain and nausea dropped from 8.5/10 to 1.83 (pain) and 4.53/10 to 1.83 (nausea) at 1 hour in the haloperidol group compared with a drop from 8.28 to 7.17 (pain) and 4.11 to 3.39 (nausea) in the placebo group. Another small, not especially well done observational study, termed HUGS, by Ramirez et al echo these findings.
  • Bottom Line:  These studies aren't necessarily practice changing but correlate with significant prior literature for pain and nausea treatment in migraines and in the anesthesia literature.It’s worth a shot to try haloperidol 2.5-5 mg IV in patients with gastroparesis (or even cyclic vomiting/cannabinoid hyperemesis although this is based on case series). It's nice to have literature out there saying "hey, this is a thing we are doing."
  • Stats/Study Design Pearl: Size does matter when it comes to the methods section. In a retrospective study you should be able to replicate the study by reading the methods. The Ramirez study had a paltry 11 sentences.

PERC - Love it but ignore it?
It’s well accepted that in a patient with low pretest probability (15% or less, i.e. Low Risk by Wells Criteria), we can rule out pulmonary embolism (PE) using the PERC criteria. The miss rate using this approach is <2%, which is the cut point where further workup and treatment would cause more harm than good (test-treatment threshold). Apparently, we suck at actually following this evidence based approach according to a prospective observational study by Buchanan et al of patients with chest pain and/or shortness of breath looked at PE testing rates in PERC negative patients. Over 25% of patients who were PERC negative underwent further PE testing and 7.2% went straight to CTPA or V/Q, skipping the d-dimer.
  • Bottom Line: If you think of working up PE, consider the patient’s risk of PE, then think of PERC, and then d-dimer before you jump to CTPA. In low-risk patients (ex: meets Wells Low Criteria) with possible PE that are PERC negative, do not do further testing to assess for PE.
  • Stats/Study Design Pearl: The test-treatment threshold is important. This is the idea that there is a point at which the harms of further workup and treatment of a disease process equal or become greater than harm of not pursuing the test. For PE this has been established at about 1.8%.

The End of Apneic Oxygenation?
Placing a nasal cannula at 15 LPM (or more) during RSI has become pretty standard practice in many ED rapid sequence intubations (RSI), often deemed apneic oxygenation (ApOx). The ENDAO trial randomized 206 ED patients undergoing RSI who had at least 3 minutes of preoxygenation to ApOx or no ApOx. Nobody was blinded. The study was looking for a difference in lowest mean oxygen saturation before groups, which they did not find (92% vs 93%).
  • Bottom Line: This study, and others like it, are negative, probably because the desaturations we are looking to prevent with ApOx are rare. ApOx may be helpful in difficult intubations or those with poor physiologic parameters who are likely to desaturate, unfortunately, we sometimes don’t know who these people are.
  • Stats/Study Design Pearl: Choice of primary outcome is important. It may seem like a difference in oxygen saturation is clinically important but when oxygen saturations are globally high, this is not going to make a difference to the patient.

Steroids for all that wheezes?
Many patients with lower respiratory tract infections (LRTI), particularly with wheezing, receive empiric steroids, inhaled beta-agonists, and possibly antibiotics (such as azithromycin), yet the evidence behind this is scare in patients without underlying lung disease (asthma/COPD). Hay et al randomized 401 patients presenting to outpatient clinics with cough and signs of LRTI who had no history of asthma or COPD to either 40 mg prednisolone daily for 5 days or placebo. They found no difference in duration of moderately bad or worse cough (~5 days in each group) or severity of symptoms on days 2-4. Of note, about 40% of the patients in this study were wheezy.
  • Bottom Line: Just because a patient with a cough wheezes, it doesn’t mean they will benefit from steroids. Keep giving steroids to patients with flares of asthma and COPD but we can be much more selective in the those without these lung diseases.

Bonus Throwback(Cutting Edge from 2010) - Stop the pulse checks in codes
We are terrible at pulse checks - they are inaccurate and insensitive. The pulse check during a code (i.e. after the initial <10 sec pulse check by a healthcare provider to establish arrest) is nowhere in ACLS. Nada. The 2010 AHA Guidelines state: "Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred." The ACLS guidelines recommend pulse checks during CPR only if an organized rhythm is seen
  • Bottom Line: Continue to assess for rhythm changes during CPR - this can take place in 2-3 seconds. There’s no need to stop for a pulse check but you may if you see ETCO2 rise significantly (just be aware it’s not very accurate). You can take a few second ultrasound clip during a rhythm check to assess for cardiac contractility.

Bonus Non-Clinical Paper - Boys > Girls?

There’s been a lot of talk about the gender pay gap, but surely it doesn’t apply to academic emergency medicine, right? Wrong. Masden et al used 2015 survey data from full-time faculty academic emergency physicians and found that women made > $19,000 less than men. You may say that doesn’t account for rank, fellowship status, administrative roles, location, clinical hours, etc. But again, that would be incorrect. That gap was after adjusting for all of these potential confounders.
  • Bottom Line: Women make less than men in academic emergency medicine. Transparency and awareness may help so share the paper with your colleagues and chairs and don’t be afraid to negotiate.

Monday, May 29, 2017

An ED Model for Shared Decision Making

The Gist: Shared decision making (SDM) is increasingly common in the ED, yet most people, particularly trainees, are untrained in this area. A proposed framework in an Annals of Emergency Medicine article by Probst et al proposes a framework to guide clinicians (or train them) in the implementation of SDM in the busy ED and combats common misconceptions regarding SDM.
  1. Ask yourself: is this clinical scenario appropriate for SDM - is there clinical uncertainty or equipoise, is the patient capable of engaging in SDM, and is there time?
  2. Have the conversation - Acknowledge that a decision needs to be made and share information about the risks and benefits of each option. Explore the patient's values and circumstances to help come to a decision.
The Case:  The nurses give you a heads up the next patient to be seen is in a lot of pain.  You see a 25-year-old healthy male who is doing the “kidney stone dance” – pacing around the room while holding an emesis basin. He's had left flank pain for the past two hours, nausea, but has a reassuring abdominal exam with minimal tenderness.  His urinalysis shows red cells in the urine and he's feeling better after analgesia.  What's next - CT scan? Ultrasound? Discharge with neither?

An SDM in the Emergency Department Framework from the Probst et al Annals article

1.  Is this scenario appropriate for SDM? 
  • Is there more than one reasonable option at this time?
The current literature regarding renal colic in the ED supports multiple options as the next reasonable

step [1-5]. Non-contrast CT scan is the historic option; yet, recent evidence supports ultrasound as a reasonable next step, and an ultrasound-first diagnostic plan might decrease radiation exposure for this young patient [2]. Experts have also argued that renal colic can be diagnosed clinically, and imaging is not necessary in classic cases with low probability of dangerous alternative diagnoses [1]. The trade-offs between these options might be important to this patient; if he’s feeling better or concerned about lifetime radiation risk, he may not want to wait for a CT scan, and conversely, if he’s about to set off hiking the Appalachian Trail, he may want to know the location and size of his stone.  
Obviously, there are clinical reasons why some cases of suspected renal colic warrant CT scans – fever, concern for an alternate diagnosis, or solitary kidney [6].
  • Is the patient able to make his own medical decisions? 
While this patient may know little about the trade-offs involved in the clinical question, research has
shown that patients do want to be told about the risks of radiation prior to CT scans [7]. This patient isn't altered or otherwise incapacitated - he can participate in decision making.
  • Do you have time? Does your patient have time?
The latter question is easy to answer: unless he’s eloped because he’s feeling better, your patient
clearly has time to have this conversation. Whether you have time depends on the severity of other patients’ conditions and your ability to explain the trade-offs in a manner that he can understand. The more you practice this skill, the better you will be at it, and it’s worth noting that the results of your conversation may speed up his discharge, creating space for another patient and increasing throughput.

2.  Have the conversation (if the answers to the above questions are yes)
  • Acknowledge that a decision needs to be made - 
“I suspect that you have a kidney stone – kidney stones cause severe pain, vomiting, and blood in the urine, all of which you had. At this point, we have to decide if it makes sense to do some more imaging.”
  • Share Information in Regard to Management Options and the Potential Harms, Benefits, and Outcomes of Each - 
“For some people, we do a CT scan – the benefit of a CT is that we know exactly how big the stone is, which helps us know if you’re going to need a procedure from a urologist to get it out. Most people with kidney stones pass the stone by themselves, and the CT isn’t helpful. The downside of a CT is that it takes time and it exposes you to radiation – and we know that every time you get exposed to radiation it increases your future risk of cancer ever so slightly. Also, if your pain comes back and doesn’t go away, it might make more sense to get a CT later – and we wouldn’t want to have to do two CT scans. Most people who have one kidney stone will have another one in the next 10 years – so you could end up with multiple CT scans over your lifetime. The other option is an ultrasound: it gives us some information and sometimes we get a CT scan if we see a lot of swelling in your kidney, but it doesn't show us how big the stone. Because I can do the ultrasound right now, people often go home sooner when they have an ultrasound, if they don’t need a CT. If we decide on the ultrasound, it’s important that you have a doctor you can follow-up with if you are feeling worse.”
  • Explore Patient Values, Preferences, and Circumstances - Probing the patient about what's important to them is key - they may not disclose difficulties with transportation, their activities of daily living, or their travel plans.
“How are you feeling? Do you have a doctor you can see in the next week or so? Would you be able to get back to the ED if you had a problem? Kidney stones usually pass in a week or two – do you have any travel planned?”
  • Decide Together on the Best Option for the Patient, Given His or Her Values, Preferences, and Circumstances
If a patient has a preference, this part is easy – maybe they’re in a hurry, worried about the cost of a CT, or have had multiple CT scans, or maybe they have an upcoming trip and want certainty.
Many patients won't have a preference, and they may ask you for advice. Share your opinion but recognize that there is a huge power differential.

“If I had a kidney stone, and the pain medication worked, I wouldn’t be in a rush to get a CT scan – but might get one in a week or two if I still had alot of pain. If I had some reason that I felt like I needed more information right now, like I was going on a cruise, then I might get the scan.”

Presenting both sides in the explanation of your opinion empowers the patient to choose either the
option you endorsed or the other option without feeling like they are disagreeing with the expert.

1. Wang RC. Managing Urolithiasis. Annals of Emergency Medicine 2016;67(4):449–54.
2. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med 2014;371(12):1100–10.
3. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol 2016;:1–9.
4. Fiore M. A proposal algorithm for patients presenting to the Emergency Department with renal colic. Eur J Emerg Med 2016;23(6):456–8.
5. Xiang H, Chan M, Brown V, Huo YR, Chan L, Ridley L. Systematic review and meta-analysis of the diagnostic accuracy of low-dose computed tomography of the kidneys, ureters and bladder for urolithiasis. J Med Imaging Radiat Oncol 2017;:1–9.
6. Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European Urology 2015;:1–7.
7. Robey TE, Edwards K, Murphy MK. Barriers to computed tomography radiation risk communication in the emergency department: a qualitative analysis of patient and physician perspectives. Acad Emerg Med 2014;21(2):122–9.

Sunday, November 13, 2016

Slaying Prehistoric Practice - Killing off the Routine Pulse Check

The Gist: It's time to kill off the routine pulse check every two minutes. While some providers and systems have moved away from routine pulse checks, perfunctory cessation in compression to identify pulses happens as 'the norm' across the United States. Perform rhythm checks, which take far less time, taking less than 10 seconds to do so. Pulse checks may be indicated if there is a perfusing rhythm and/or other signs of ROSC. 

Most of us recognize that, to the best of our knowledge, interruptions in chest compression may be deleterious to return of spontaneous circulation and, theoretically, neurologic outcome [2]. We may even devise complicated ways of reducing time without compressions including mechanical compressions and hands-on defibrillation. These interventions are not evidence-based and the yield is minimal. A more simple fix exists - stop checking for pulses routinely.  This isn't some novel wild idea.

The American Heart Association guidelines do not recommend any specific interval for pulse check after the first initial pulse check for healthcare providers [3].  Beginning in 2010,  however, the AHA guidelines begin discouraging routine pulse checks:
"Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred" [4].

It's really difficult to identify pulselessness in < 10 seconds
. Few people can determine the presence of pulselessness in 10 seconds. Dick et al performed a study of patients placed on cardiopulmonary bypass, and providers were blinded to the presence of pulsatile flow. Only two percent of experienced providers (n=209) were able to determine that a patient was pulseless in under 10 seconds [5].
Enforcement of time between compressions may be mitigated by having someone count down from 10 during the rhythm analysis. We often have the individual performing chest compressions do this and they are trained and reminded at the beginning of the resuscitation to resume compressions when they reach zero.

Pulse checks are inaccurate. A study by Tibaballs et al again had providers assess for a pulse in patients on bypass with and without pulsatile flow. They found 78% accuracy in identification of the presence or absence of a pulse [6]. While an accuracy of 78% may seem high, this means that approximately one in four times we are wrong. This means we may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions. Cardiac ultrasound and arterial line tracings demonstrate contractility and flow with superior diagnostic characteristics, although each has their limitations [7].

Why would we undertake a diagnostic strategy if we know it it is inaccurate and insensitive? Changing practice is difficult. In critical situations, we default to what is familiar, what we know.  It is time to move away from the pulse check. We may still need to check for rhythm analysis at periodic intervals, and this is supported by the AHA guidelines. Some monitoring systems allow for this concurrently with compressions (filter out the baseline), while others do not. Many of us are also compelled to search for reversible causes of arrest with ultrasound, many of which do not require an interruption in compressions.

How do we determine ROSC, then?
The AHA recommends arterial lines, ultrasound, rise in end-tidal capnography to 35-45 mmHg, or pulse AND blood pressure. In the emergency department, we often have access to ultrasound, arterial lines, and ETCO2.

If you're curious about why we are so stubborn to let go of our practices, check out this post on unlearning practices we adore.

1. Soar J et al. "European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support." Resuscitation, October 2015, Pages 100 - 1472.
2. Eftestøl T, Sunde K, Steen PA.  Effects of Interrupting Precordial Compressions on the Calculated Probability of Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation.2002; 105: 2270-2273.
3. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support. Circulation. 132(18 suppl 2):S444-S464. 2015
4.Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
5. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000 Nov;28(11 Suppl):N183-
6. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010.
7. Gaspari R et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27

Unlearning - Yoga For Your Brain

The Gist:  Knowledge translation is a problem in medicine and, at the individual level, unlearning likely contributes to the knowledge translation gap.  It may also exist as part of the solution. Akin to yoga, unlearning requires flexibility, training or deliberate practice, and is enhanced by a community open to skepticism and growth.
  • Note: These musings are not evidence based but are more of a cognitive framework to understand why we have such difficulty individually changing practice.
For an introduction to unlearning, check out this post.  In brief, unlearning, while really an aspect of truly understanding and learning, is complicated.  Most of us find it relatively easy to stuff more information into our brains, a process we perceive as "learning."  Nasal cannula with oxygen at 15 liters per minute plus may help prolong safe apnea time and reduce hypoxia during intubation?  Cool, we can do that.  However, when we are told that something that we routinely do or believe may not necessary or even harmful, we often have more difficulty changing out behavior or "unlearning." Intubating patients with out of hospital cardiac arrest may not be helpful? Preposterous! Unlearning a bit of information is unnatural, it may feel awkward whereas learning, as it often does not put our knowledge or ego in jeopardy.

Flexibility - Unlearning requires cognitive flexibility. When we stretch our bodies, we reach a point where we feel a burn; our body telling us we are approaching our limit. We can push further safely, it just burns slightly more.  Unlearning is essentially the same and is often accompanied by “the burn.”  When we come across information counter to the way we practice, it stings. We may feel defensive. This is “the burn.”  We experience discomfort when we stretch our thinking beyond this. This may be, in part, because we are emotionally tied to our knowledge. We work hard for what we know.  We act quickly in emergency care and must have confidence in what we know, as emergent situations do not typically allow for debate or significant time to think.

  • A fix: When one feels “the burn” when confronted with new information that runs counter to our practice, recognize that this is a warning sign that knowledge may be changing.  Recognize that the sting comes from our ego, protecting what we know.  This does not mean that one should change practice whenever we come across a piece of novel information. Rather, we should we aware that in order to practice evidence based, up to date medicine, we may feel discomfort. When our beliefs are challenged, instead of becoming defensive, we should thoughtfully consider the information.
Training - Mastering a yoga pose requires training and deliberate practice. In order to unlearn ways of thinking, we must also engage in mental preparation and practice.  It is easy, particularly in emergency settings when adrenaline dominates, to think and execute in a perfunctory manner. We default to what we know and what is familiar.
Some fixes:

  • Early Exposure - The earlier we begin training, the more prepared we are. If one has an upcoming race, we may expect we will perform better if we begin preparing earlier rather than the week before the race. Similarly, when it comes to unlearning a habit or a way of thinking, the sooner we are exposed to the contrary argument, the more prepared we may be to unlearn.  This may serve as a preconditioning so that we may react less strongly upon repeat exposure. 
  • Repeat Exposure - Practice is central to most athletic endeavors. The more repetitions we do, the stronger we become.  The more we practice a yoga pose, the more likely we are to be successful, the more comfortable it will feel.  Unlearning is easier when we are exposed to the target bit of knowledge more frequently.  Spaced repetition exists as one of the most evidence-based means of learning and  this probably applies to unlearning. 
Community - Yoga and CrossFit are associated with strong communities, as are many team sports.  Communities may motivate us, hold us accountable, and push the bounds of our perceived capability.  Studies demonstrate that physicians practice similarly to the institution where they trained and show a wide array of geographic variation in practice patterns. A network of peers and colleagues, particularly outside of own’s main “system” or hospital, may increase our cognitive flexibility by exposing us to a wide array of practice pattern.  The Free Open Access Medical Education (FOAM) community may expose to novel and controversial information.

Unlearning in the Prehospital Arena: The Workout
Needle Decompression for Tension Pneumothorax (see this post or this podcast).  The second intercostal space at the midclavicular line (2nd ICS MCL) has been taught as the ideal spot for needle decompression.  This, however, is changing.  New recommendations are to use a catheter at least 8cm in length if needle decompression is attempted at the 2nd ICS MCL or decompress at the fourth or fifth intercostal space at the anterior axillary line (4/5th ICS AAL).
The chest wall is thick at the 2nd ICS MCL [1,2].  Radiographic studies of chest wall thickness demonstrate increased thickness at the 2nd ICS MCL compared with the 4/5th ICS AAL (4.78 cm vs 3.42 cm).  Even ATLS states that needle decompression in the 2nd ICS MCL will fail more than 50 percent of the time.  This is an intervention undertaken in extreme circumstances in critically ill patients.  A chance of failure of 1 in 2 is unacceptable.
The 2nd ICS MCL is difficult to identify [3,4].  The clavicle extends further than most people think. As a result, providers are less accurate in identifying the 2nd ICS MCL compared with the 4/5th ICS AAL.

The pulse check.  If one were to survey cardiac arrest resuscitation across the United States, in and out of hospital,  we would probably see that the majority of people pause every two minutes for a “pulse check” despite decreased emphasis on the pulse check by the AHA guidelines over the past 10 years.  The guidelines recommend minimal interruptions for pulse check and detail the problematic sensitivity and specificity of pulse identification [6].  After the initial pulse check prior to CPR, the guidelines don’t actually specify any time frame for repeat pulse checks. Yet, many of us do.  Sure, we can pause for rhythm analysis; however, many systems and the European guidelines now recommend pulse assessment upon observation of an organized rhythm or increase in end tidal capnography [7].
Few people can determine the presence of pulselessness in 10 seconds. Dick et al of patients placed on cardiopulmonary bypass and providers blinded to whether or not the patient actually had a pulse. Only 2% of this cohort of experienced providers were able to identify a pulseless patient in 10 seconds [8]. With increased emphasis on compression fraction, this may result in a delay in resumption of compressions.
The accuracy of the pulse identification by providers is suboptimal, noted to be 78% in one study [9].  While an accuracy of 78% may seem high, this means that approximately one in four times we will be wrong. We may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions.
For more on this topic check out this post and/or this post.

Left Bundle Branch Block (LBBB) as a STEMI Equivalent (check out this post)- Prior to the 2013 iteration of the AHA guidelines for ST-elevation myocardial infarction (STEMI), new or presumed new LBBB existed as a “STEMI equivalent.”  This often activated the cath lab and STEMI teams.  In 2013, the AHA removed this from the guidelines yet these patients are often referred to the emergency department for “rule out MI.”
Further, STEMI may often be diagnosed on ECG, using the Sgarbossa or modified Sgarbossa criteria (link) [10].

Backboards - fortunately protocols in many states and systems have dispensed with long backboards.  Long thought to be protective, despite known harms, the American College of Emergency Physicians released a guideline in 2016 explicitly stating that long backboards should not be used as a therapeutic or precautionary measure. They cause harm and don’t help. [11]

Oxygen in Acute Coronary Syndromes - Aspirin, oxygen, and nitroglycerin have long been the initial interventions for patients with suspected ACS. Recent studies have found no clear benefit for oxygen in patients with normal oxygen saturations. Further, one study found oxygen was associated with markers of larger myocardial infarctions (although this is not a patient-oriented outcome) [12]. The AHA recommends oxygen is appropriate for patients who are hypoxemic (oxygen saturation < 90%) [6].

1.  Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16.
2. Advanced Trauma Life Support, 9th edition.
3. Ferrie EP et al. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005;22(11):788–9.
4. Inaba K et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers
6. Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
7. Resuscitation. 81(6):671-5. 2010.
8. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse?Crit Care Med. 2000 Nov;28(11 Suppl):N183-5
9. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation.
10. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 61(4):e78-e140. 2013
11. "EMS Management of Patients with Potential Spinal Injury." ACEP Board of Directors. Available at:
12. Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 131(24):2143-2150. 2015.