EMRAP and AIR Procedures (Sept 2019)
AIR: https://www.aliemu.com/courses/procedures-2019/
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
https://www.emrap.org/episode/emrap20194/againststress
When you have finished listening to the podcast, answer the following questions:
1. Please list three things you learned from this podcast that you were not aware of before.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
3. What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
3 comments
This month’s EMRAP was totally awesome, because there are two segments I particularly loved. First off, the superstitions segment is amazing. All the myth debunking aside, I think this segment highlights the unusual ways that research can be conducted in medicine. I love the notion of an RCT to test the “quiet” theory. This underscores the possibilities for research, and how if there’s a notion out there then you can study it (and get published) regardless of how “non-scientific” that theory may be.
I am also a huge fan of the Helicopter EMS section. Vahe Ender (one of our medflight guys) did a talk on this exact talk at SAEM in Vegas, and this piece overlaps a lot with his talk. It is a good reminder of how fortunate we are to have Boston MedFlight, and how different it can be in other parts of the country.
The RASP section was also high yield, as I have had a lot of needle stick patients, and most of the time seems to be spent discussing risks, etc. Having a tool to assist in this conversation will be very helpful.
Finally, I also really enjoyed the US for dissection segment. About a year ago they discussed a similar topic in the context of STEMI, encouraging at least a quick view at the aortic root prior to heparin. That has become my practice, under the notion that eventually I’m going to save someone whose STEMI is 2/2 dissection. The standardization of an aortic protocol would be of huge benefit, and I’m pleased they are pushing forward this concept.
Three things I learned and how it would change my practice:
1. The stress test segment was incredible. I read Morgenstern’s 5 page post on this a month ago and was fired up about it then, but having him speak about it more succinctly nailed down the take home points. I think institutionally, this is far from where we are at at BMC at this point which I’ll talk about below. The most reassuring point is that our miss rate is much much lower and if we expanded this to include only patients with two negative troponins (our typical ACS workup), we would probably miss less than 0.1% of MI’s. It’s also interesting to say that patient’s who have an MI or die within 30d of discharge are included in the negative outcomes, which for many of our most high risk patient’s, it’s tough to say that if they had an MI 28d after an ED visit for chest pain, that any admission or provocative testing would have helped that acute plaque rupture on day 28 that caused their negative outcome. Additionally, it was interesting to see that even in angina, most of the data that supports their use has to do with subjective improvements in quality of life without any associated improvements in morbidity/mortality.
2. Loved the deep dive into contrast induced nephropathy (CIN). The data from the trials he presented was really unimpressive and poorly performed. No control groups, differences in baseline characteristics of the two groups, average Cr not changing yet the studies would focus on the 2% of patients that had increasing Cr (and ignoring the 2% with improving Cr after CT) are just some examples of the problems with the data. Particularly interesting was that even in patient’s that don’t receive contrast, 5-15% will have AKI during the first 5 days of their hospital stay which if they had had a CT would likely have been attributed partially to the contrast.
3. Discharge instructions through the lens of a lawyer. I think that we could do a lot to improve the quality of our discharge instructions, and it’s awful to say, but I’m most interested in the legality issues of discharge instructions. Our epic pre-formulated instructions are largely or poor quality, and I think that having a unifying BMC discharge instructions smart phrase would be beneficial to having more uniform precautions for patients. Particularly the verbiage of “Sometimes dangerous conditions take time to manifest themselves, so while this is unlikely at this time, please insure that you follow up as we discussed” – I often struggle to find a reassuring way to tell patient’s that they should still be vigilant for developing conditions. Finally, it’s scary to think of all the discharge instructions that I have said follow up with PCP in 1 week especially since our patient’s likely won’t even be able to follow up in 1 week within our system – which kind of leaves returning to the ER as their only reassurance.
Too cutting edge for BMC:
– No stress testing – we are far from this target at this point. I would say that I Obs the majority of patient’s above 60 years old with chest pain despite negative trops. Further, working recently with the extreme boarding, we often get to the 16-24hr mark with these patients and I’m not sure what the obs unit typically does for these patients at that point, are we consulting cardiology on every CP rule out admit to determine the type of stress testing?
– Contrast induced nephropathy – we are still often held to having Cr on patients in order to give a contrast bolus. However, the trauma room often facilitates us forgoing bloodwork for an emergent contrasted scan. I would hope a similar work flow could be developed for side patients so that the ER physician is able to make the call (and potentially take the liability) for doing a contrasted scan on a patient with CKD.
– Ketamine for agitation at BMC is often treated as similar to 5+2 and often results with the patient on a monitor and a 1:1, but not with 1:1 nursing or q15 min checks. The safety profile of ketamine in our ER seems excellent, but I do wonder if we should be using more resources to monitor patients that get ketamine which would cause huge issues with nursing resources. This is further problematic because I could see us going back to haldol and midaz/ativan if we wind up being required to treat it as conscious sedation even though it seems that ketamine works far better.
1. I hadn’t heard of the VAN score to assess for LVO before. It’s cool that one can rule out LVO if arm drift isn’t present! The caveat that it hasn’t yet been validated for prehospital providers means that people will still be using various other systems (such as FAST-ED here in MA, which as a paramedic I can never remember). The segment on superficial venous thrombosis was really interesting, because that’s not something I had heard about before (regarding anticoagulation). I won’t remember the cutoffs that Dr. Avila uses to initiate treatment, but I will be likely to reach out to consultants for advice if I find a patient with (?)SVT. The segment on breastfeeding was very informative because that’s something with which I have no experience and hadn’t given much thought to.
2. I don’t think there was too much in this particular episode that will directly change my practice. I will keep an eye out for validation studies on the other LVO screening scores. I will also try to do more DVT ultrasounds and echos on chest pain patients.
3. Even though the evidence is vast that stress testing is not great, I don’t think it’s time for practice change because that will require a culture shift within the hospital, cardiology groups, and PCPs.