The Gist: Although emergency medicine has a reputation for being algorithmic, there's a good amount of variation in thinking and practice. This is necessary (variable resources, different patient populations) and can be excellent (promoting growth, change, and innovation). The foundation for our practice is built in the training we receive, both in text and from our local educational community. FOAM has played a role in laying the foundation to what will become my EM practice and I think that FOAM has the ability to lead to improved patient care through discourse on evidence based medicine, updates on current practice, and insight into the thought process and practice of others (shared learning!).
After spending my third year of medical school in rural Alabama and absorbing a good bit of EM FOAM, I thought I should experience the cutting edge, academic side of EM. Realizing, through heated Twitter debates, that emergency physicians actually approach many situations rather differently, I wanted to lay a broad foundation of practice...knowing I would probably practice most similarly to wherever (and with whomever) I train. Over the past six months, I had the privilege of training in seven excellent EDs in five states with the smartest people I've met. Below is a smattering of bread and butter things I found...(limitation: this is clearly a small sampling of each institution due to my limited time).
Apneic oxygenation/high flow nasal cannula during intubation (NODESAT - nasal oxygen during efforts securing a tube). One institution had adopted and implemented this by the time I rotated through, another started this after a virtual grand rounds lecture with Dr. Scott Weingart. Pulse ox lag is real and few people talked about it in airway situations. Check out this EMCrit podcast and this PHARM post on the subject.
What do a pulse oximeter and The Delorean have in common?Both are time machines; Know & respect pulse ox lag @emcrit twitter.com/RobJBryant13/s…
— Rob Bryant (@RobJBryant13) December 18, 2012
- Evidence: Preoxygenation, Reoxygenation, and Deoxygenation by Weingart and Levitan.
The oxy-hemo-coaster: scariest ride in the resus room, respect the oxy-Hb dissociation curve and pulse-ox lag twitter.com/RobJBryant13/s…— Rob Bryant (@RobJBryant13) December 18, 2012
Use of droperidol. Places either use it liberally or refuse to use the drug, as I discussed in this post. At an institution that no longer uses droperidol, an attending went through the paucity of evidence behind the black box warning as well as the political/economic factors that likely played a role in the downfall of droperidol.
- Review of the FDA black box warning cases associated with low dose droperidol (0.625-1.5 mg) showed that the 10 cases reported occurred in patients with known or suspected cardiac issues.
Use of ketamine. FOAM teams with enthusiasm for ketamine (see any tweet by @embasic or @MDAware, this multi-national podcast, or one of many EMRAP episodes), but I saw this drug rarely used outside of pediatrics in all institutions, the most notable exception was to intubate asthmatic patients. Why does this matter? Procedural sedation can be tricky and I witnessed some that were executed well and others that were less than ideal. In addition to the amnestic properties, ketamine confers some analgesia and has less respiratory depression (clinically relevant, that's uncertain). Furthermore, one ED I rotated through had zero etomidate available. We used whatever was available for RSI and thus, needed to be familiar with a cornucopia of agents. This includes ketamine, which has showed excellence in induction for RSI, including in this recent study.
Make Ketamine Work For You: Along with droperidol and dexamethasone, ketamine is on my short list of favorite me... bit.ly/Y56aR7
— Ryan Radecki (@emlitofnote) November 28, 2012
- Here are the ACEP clinical practice guidelines for the use of ketamine in the ED, which articulate that ketamine in high ICP is ok (myth busting article). The guidelines also say that ketamine shouldn't be used in elevated IOP, something not born out by recent literature (Keeping Up! review, Drayna et al article).
Quantitative capnography (ETCO2). Not routinely used after intubation or for procedural sedation in 5 of 7 institutions, although infrastructure was the limiting issue at one institution, which has since been rectified. However, the FOAM community has referred to it as a 'standard of care," including Dr. Scott Weingart in his review of NAP4.
- An evaluation of procedural sedation, ETCO2, and the evidence by Dr. Chris Carpenter
- A great review of ETCO2 in cardiac arrest from St. Emlyn's blog.
- Capnography cheat sheet from EKG Press
Treatment of an abscess. At nearly all institutions, antibiotics were prescribed following an I&D of an abscess, although almost all attendings mentioned that one could "probably get away without them" A minority of cases had significant surrounding cellulitis or immunosuppressed states. Three of six places had me pack abscesses, although this was more attending dependent than institution dependent. The Skeptics Guide to Emergency Medicine's podcast #13 is a great review (free registration required) of the evidence base behind packing and antibiotics. Freeemergencytalks.net also has a great talk on the subject.
- Antibiotics - a review, demonstrating that most abscesses don't need antibiotics. Antibiotics also carry harm, from resistance to Steven-Johnson and diarrhea and this recent article in Pediatrics shows that TMP-SMX adverse effects are on the rise, likely secondary to profound administration for skin and soft tissue infections.
- What about MRSA abscesses? Here are some EBM guidelines.
- 90% of patients with MRSA abscesses will do just as well without antibiotics (Rajendren).
- What about recurrence? Less recurrence by day 10 but no change at 30 days.
- Packing - The NNT summary of a small study, demonstrating no benefit to packing abscesses. Confirmed in this Kessler et al study. During ICEM 2012, there was much tweeting on packing in an era in which some abscesses undergo primary closure (across the Atlantic).
- Use of ultrasound for drainage. We did this at two of five institutions. In fact, at a community hospital that was not very ultrasound keen, an attending suggested that we ultrasound first. We saved that patient an incision as she had no discrete pockets to drain. SonoSpot post, Adhikari, Blaivas article
- NB: Much of the literature on this topic is from the surgical literature, which is not exactly equivalent; however, the ED literature base on the topic is growing.
Central lines. Sterility is key and, with the exception of code lines, was excellent at all sites. Line placement varied quite a bit. In 2012, the femoral line seemed to make a comeback in some literature and in the FOAM sphere (PHARM podcast, EMCrit). For the problems (DVT, infection rate) attributed to femoral lines, I saw (and placed) a surprisingly high number. There was one in-ED IO insertion during all of my rotations. Beneath the clavicles, ultrasound hadn't captured the attention of many.
- Code line of choice: Subclavian-4, Femoral-3.
- Use of ultrasound in code lines: 0.
- Use of ultrasound in femoral lines: 0.
- Small study: not slower than landmark approach and had better success. It's a small study, but I've seen non-code femoral lines in awake, conversant patients, take many attempts from multiple people prior to establishing a successful line. Ultrasound, if one practices, actually speeds things up (and may save the patient multiple sticks).
- Use of ultrasound in subclavian lines: 0.
- Check out this PHARM podcast. Study in Critical Care Medicine demonstrating the superiority of ultrasound guidance in critical patients (not necessarily coding patients).
- Use of ultrasound in the IJ: 7.
Ultrasound. Each academic center used ultrasound heavily but the community hospital used ultrasound solely for FAST scans and placement of internal jugular central lines. At the community institution, they often laughed as I dragged the single SonoSite Titan from room to room and enthusiastically discussed what I could do with a linear array probe. It speeded things up, though, when I presented my patient noting that I had already visualized the IUP and documented a fetal heart rate (or not, as was the unfortunate case sometimes) or documented a normal caliber aorta, B-lines, etc. When I diagnosed an SBO in mere seconds, one of the doctors was sold and disposition was easy. Billing for scans and the practice of ordering confirmation scans seemed to vary the most. Also, utilization of ultrasound seemed more attending dependent than necessarily institution dependent since training and credentialing are still being worked out in many settings. Listening to this episode may have been beneficial.
Observation units. All but one place I rotated at had an observation/clinical decision unit (CDU) and the one place that did not have one, incorporated one by the time I returned a few months later. These units provided a monitored setting where patients could have cardiac enzymes drawn for rule-out protocols, receive antibiotics, or receive rehydration, etc. Anecdotally, these seemed to improve workflow and allow easier disposition, something supported by literature (Trzeciak, Schneider, Gordon). In the cardiac setting, use of these seemed to buy most people either a stress test or CCTA on the spot, depending on the institution. Although this practice is supported by the AHA, evidence seems to be mounting that this may be unnecessary and costly (See EMRAP November 2012 with Dr. Scott Weingart and SMART EM summary and podcasts on this topic).
- FOAM conversations often revolve around direct laryngoscopy (DL) versus video laryngoscopy (VL) (ex: PHARM podcast 51 and post, EMRAP 9/12). DL served as the primary means of intubation across the board and residents and attendings preferred this modality. Each institution had at least one VL in the ED, predominantly the glidescope (although one had one in the 'resuscitation area,' a slight trek in an unpredictably difficult intubation). Two of seven places had combined VL/DL devices available but I didn't see these used during my rotations.
- Post-intubation sedation (vital!) was not always ordered, but was not an institutionally dependent thing. Attendings at one institution seemed to consistently stress ordering sedation at the time one was ordering the paralytic and induction agents versus waiting until afterward.
Weingart 19: take 2 fingers and jam them DOWN YOUR THROAT. This reminds you to treat your intubated with ANALGESIA. Fentanyl,opiod#acep12
— jeremy faust (@jeremyfaust) October 10, 2012
In EM, there are constants as well:
- The physicians were incredibly smart, motivated, and passionate
- Emergency physicians know how to have fun
(EM clerkship wakeboarding and hiking days)
Personal thought: FOAM levels the playing field with regard to access to information, something that can be amazing for community physicians removed from the academic setting, busy physicians, or those in more remote locations. I am incredibly excited to see how FOAM can continue to evoke dialogue about (and create) variations in practice to achieve better quality of medicine - on individual, community, and international levels.