EM:RAP and AIR Lower Extremity Orthopedics (Dec 2019)
AIR: https://www.aliemu.com/courses/orthopedics-lower-extremity-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/emrap201910/december
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
1. Please list three things you learned from this podcast that you were not aware of before.
a) Awesome piece on drugs to be avoided. I especially like the line, “Tramadol is a drug searching for an indication.” 100% agree on kayexelate, I learned a ton about it in med school and will probably never use it. Good reminder to avoid dopamine as a pressor, especially in pediatrics.
b) Good point about beta blockers in cocaine chest pain. There hasn’t ever been a role for beta blockade early on in chest pain related to coronary vasospasm or CAD, including suspected ACS, though it’s worth noting that the AHA recommends starting a beta blocker in STEMI/NSTEMI patients within 24 hours, and that shouldn’t be ignored. But there’s no rush.
c) Mailbag- I’m looking forward to the day where I can take a picture of a patient and have an AI risk-stratify them for ACS. As a junior learner, I’m going to hold on to the HEART score for just a bit longer, but I am starting to develop a mental model of ACS and CAD. I like to chart stalk my chest pain admits to see if they get cath’ed etc, which helps.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
Oxygen for presyncope! Interesting concept, I’m probably not going to use it regularly for people who feel vaguely unwell, but similar to the anecdote in the podcast, I might consider it for peri-procedure squeamies.
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?
-End tidal O2 sounds expensive. It looks promising, but definitely needs more data on outcomes and needs to be compared to a standardized protocol for pre-oxygenation.
Three things I learned and how they will change my practice:
1. Ouchless ED – often BMC feels like a “just get it done” environment where patients are expected to bear their teeth through deep USIVs or fast anesthesization of lacs/abscesses. We have several of the tools mentioned in the ouchless ED segment, they are readily available in the peds ED. Most of our time our patients are waiting for an open room for a lac repair/abscess, and we could likely use EMLA or other topical applications to lessen the initial pain. Mainly, I’ve realized my best attempts at procedures come when both myself and the patient are relaxed which can often be achieved with just casual conversation to distract the patient +/- some versed if it’s a larger procedure like an LP.
2. Human factors in resus – very happy to see Ron running some in situ sim in trauma 3 this year, this has definitely improved the language/roles of the trauma room. We could definitely do more to improve closed loop communication in the trauma room – given all the new nurses in the ER, I am still strongly in favor of a nursing facesheet but know this is unlikely to happen. The best case scenario is having some time to meet the team in the room prior to the case beginning if you’ve had ample heads up from EMS, then you can assign roles and review names – this is what he describes as the “pre-brief”. We have some established lexicon like MTP and primary/secondary, and I will try to continue to be specific when I announce things to the room when leading a trauma, and to specify an individual when I need something.
3. Mailbag – in the ever evolving quest to predict ACS risk, I enjoyed the discussion of the HEART score and how risk factors are useful in long term risk, but for an individual ED visit, long term risk factors are unlikely to predict acute risk. In this sense, the HEART score has unequally weighted components with far more predictive value on the troponin/ekg/story. Further, in a study of risk factors as a predictor of ACS in an ED visit, female patients presenting with chest pain did NOT have a statistically significant OR for ACS with +risk factors, meaning again, anyone is entitled to ACS at anytime and woman have particularly poor predictive tools.
Too cutting edge for BMC
– End tidal O2 – definitely far from useful at this point at BMC and too expensive. However, the studies they quote show with objective data from end tidal o2 that our current preoxygenation strategy should be effective for patients in washing out the lungs with o2.
– Geriatric medication assessment – its substantially difficult at BMC to get a complete home med recc in any timely fashion, so trying to change outpatient medications is very difficult. Until we have better outpatient follow up for patients and better primary care communications, I doubt that we will be able to do much in the way of medication interactions/BEERS medication assessment in the ER.
1. Some of the pediatric pain control techniques like breastfeeding or the “buzzy bee” I’d never heard of before, but I’ll be sure to consider in the future. The geriatrics section made the excellent point that geriatric patients presenting after a fall or multiple falls should get a fall assessment. I think we often just work them up to determine what injuries may have happened and then kind of leave it there unless they’re clearly unsafe to go right back home. I loved the “Med Zeppelin” segment both for the learning pearls and the Led Zeppelin song clips. One of the really interesting pieces was that sodium bicarbonate increases intracellular acidity and may actually worsen cardiac arrest mortality.
2. I will make a more concerted effort to “pre-brief” the resuscitation team members when able. This is really effective at getting everyone on the same page and decreasing confusion.
3. In the ethics section, they discussed how there is no moral obligation to continue ineffective treatments. I remember learning similar things in medical school. In practice, however, I’ve always found that it’s not that simple with critically ill patients. Each instance where we’ve wanted to stop an ineffective or futile treatment, it has required complete family support or ethics and/or palliative care consults.