EM:RAP and AIR Hospital Acquired Pneumonia (Oct 2019)
AIR: https://www.aliemu.com/courses/capsules-hospital-acquired-pneumonia/
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/emrap20196/cardiology
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?
2 comments
Three things I learned and how would it change my practice:
1. The post arrest cardiac cath piece illustrated some of the ongoing controversies I’ve experienced at BMC about post-arrest management. I’ve had multiple recent patients who had vtach during their resuscitations (not necessarily their initial rhythm, no STEMI on ROSC) who have gone to cath without any interventional lesions. The date seems to support that only post-ROSC STEMIs and initial vfib rhythms tend to have a high yield of culprit lesions that may lead to better survival with an immediate cath. The cath lab is a substantial resource to activate, and given this paper and the current state of the literature, I think I would continue to agree with our cardiologists that generally non-stemi, non-vfib arrests should not have immediate cath lab activation (which may even delay other interventions to determine other possible causes of the arrest).
2. Contrast induced nephropathy – This has been an ongoing conflict nationally, but certainly at BMC as well. Delays in emergent CTs while waiting for creatinine to result, or arguments that the yield of the study outweighs the risk of CIN leading to delay in the scan. The trials they reference show equal rates of increasing and decreasing Cr after contrast boluses, essentially meaning that acute kidney injury is not related to contrast use, but rather people admitted to hospitals often experience AKI regardless of contrast use. Not to mention many of the referenced studies are >10 years old. Furthermore, none of the studies demonstrate a correlation with needing dialysis, it seems more often it’s just that the patient that gets treatment of their underlying disease (which may have been diagnosed on CT) and trending of their Cr until resolution.
3. Ketamine – When agitated patients get ketamine IM at BMC, they don’t undergo the formal procedural sedation requirements. They don’t get assigned 1:1 nursing, although depending on the patient, we do initiate EtCO2 on these patients for monitoring, and they should always have a real bed, not be stationed in the hallway. Sacchetti’s opinion that ketamine should not be used for agitated delirium is concerning, because I do agree that in undifferentiated agitated delirium, ketamine will mask the underlying problem, and patient’s could run the risk of not being appropriately monitored or treated for an underlying cause to their delirium. However, he offers that droperidol/Haldol/benzodiazepines can be used without needing to employ the procedural sedation precautions, and I’m not sure that the data agrees that rates of respiratory depression or mortality after more classic B52s are less than in the use of ketamine. In my anecdotal experience, ketamine is more reliable and less likely to oversedate your patient, whereas we often have MICU patient’s admitted for substantial benzo/Haldol use. I think his point is larger in that we have an increasing number of agitated patient’s in the ER, particularly in the setting of recent meth use in Boston, and the underlying issue is that anyone requiring chemical restraint is at high risk for complications, and we are understaffed to appropriately monitor these patients as they often tie up our limited “rooms” for 10+ hours.
Too Bleeding edge for BMC:
– Handwashing – maybe one day the sanitizer pumps will have fresh batteries. Probably too bleeding edge. Luckily we are no longer a department with white coats and ties, so that is better for infection control.
– Standardized discharge instructions are a great idea, and BMC would benefit with a better repository of discharge instructions. Right now it sounds like the hospital is crowd-sourcing some discharge instructions which will be very helpful.
– I’m not sure if hemophilia is too “bleeding edge” for BMC, get it, bleeding edge
– The portion about the reporting system for law enforcement in the ER was interesting. STARS reports focusing on patient advocacy particularly in the treatment of prisoners would be an excellent idea for BMC. This is currently being done in an informal manner, but as a community focused on patient equity, I think we would benefit from a “social advocacy” stars reporting system
This was one of my favorite EM:RAP episodes to date and I learned a lot of things:
1. I had no idea how to dose factors XIII and IX for hemophilia; I’m sure I’ll forget this soon, but at least I’ll have a sense of what it should be and be able to look it up quickly. Really cool segment. I learned a lot on the CIN segment as well; I have heard from numerous sources that CIN is, by the evidence, a myth, but I didn’t know the actual evidence. For a third thing, I found the segment on discharge instructions very relevant and important; this is something that we do thousands of times per year and can lead to poor post-discharge adherence to medications and follow up as well as open us up to unnecessary liability.
2. Piggybacking off the last item above, the discharge instructions segment has already changed my practice and the way that I supervise and teach medical students and junior residents. For one thing, I no longer recommend 1-2 week follow up for most things (except ortho or when specialists recommend that interval). I had thought that as most people can’t realistically get into their PCP within a few days that it’s more accurate to space out the follow up interval. However, the truth is that while most people are fine to follow up then, it is doing patients a disservice to suggest that close follow-up isn’t needed because we can’t be 100% sure of anything and may be missing a more serious injury or illness in its early stages. The segment on handwashing was really interesting. I wash my hands and stethoscope regularly, but hadn’t thought about my watch or phone or other objects. Should my future attending job(s) require a white coat, I will also be much more cognizant about having it cleaned regularly.
3. The segment on cardiac cath is, per my usual comments on cardiology practice, not necessarily ready for prime time because we are not the ones performing that procedure and therefore that would only become practice/policy after multidisciplinary discussion and agreement.