ACEP NowACEP Now http://www.acepnow.com Fri, 16 Feb 2018 02:14:33 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 Published Clinical Decision Aids May Lack Validation http://www.acepnow.com/article/published-clinical-decision-aids-may-lack-validation/ http://www.acepnow.com/article/published-clinical-decision-aids-may-lack-validation/#respond Thu, 15 Feb 2018 14:47:39 +0000 http://www.acepnow.com/?post_type=article&p=18521 The physician life has never been “easier.” We live in a fortunate future, replete with information technology...

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The physician life has never been “easier.” We live in a fortunate future, replete with information technology at our fingertips, along with the decision support to suit our every clinical need. What tremendous satisfaction we all must take with the various epiphanies and pearls presented to us by our electronic health records. Independent thought, along with clinical judgment, is being rendered obsolete.

A steady diet of academic research inflates our fulsome girth of clinical calculators, shortcuts, and acronyms. NEXUS! PERC! HEART! HAS-BLED! The siren’s call of simplicity and cognitive unburdening is insidiously appealing. With progress, unfortunately, also comes folly. Are these tools actually smarter than the average bear? Does this ever-expanding cornucopia of “decision support” actually outperform a trained clinician?

Perhaps a better question is, is anyone even asking that question?

It’s troubling that this does not appear to be the case. A recent historical review in Annals of Emergency Medicine looked back at 171 research articles evaluating the performance of decision aids.1 For a decision aid intended to be incorporated into routine practice, it should seem reasonable not only to simply statistically validate a prediction but to also ensure it outperforms current clinical practice.

Of the 171 decision aids included in their survey, the authors were only able to identify 21 publications either in Annals or another journal in which the aid was compared directly to clinician judgment. In the remainder, no comparison was made or could be identified in the external literature. Of the handful for which a comparison was identified, the results are, unfortunately, discouraging. In these 21 comparisons, the decision aid was clearly superior to clinician judgment in only two. The two comparisons favoring the decision aid were a prognostic neural network for outcomes in patients presenting with chest pain—effective but too unwieldy for widespread use—and the useful and well-studied Canadian C-Spine Rule. Conversely, six decision aids clearly underperformed as compared to clinician judgment, and the remainder were a wash. Examples of popular decision instruments either inferior to or no different than clinician judgment included the Alvarado score for appendicitis, a general evaluation of pediatric head injury rules, risk-stratification rules for pulmonary embolism, and the San Francisco Syncope Rule.

A mere 21 publications hardly represent more than a tenth of their survey substrate, and it would be erroneous to assume those left untested are equally unreliable. It is also reasonable to suggest the decision aids for which the comparisons showed no difference may have suffered from flawed comparator study design rather than a failing of the decision aid itself. Regardless, it should certainly not instill any disproportionate confidence in clinical decision aids as a replacement for thoughtful clinical judgment and experience.
A salient contemporary example of a decision aid of questionable value versus clinical judgment is the Ottawa Subarachnoid Hemorrhage Rule.2 This rule, derived and described originally in JAMA, then recently validated prospectively in the Canadian Medical Association Journal, targets an important clinical question: Which patients with acute headache should be evaluated for subarachnoid hemorrhage (SAH)?2,3 Patients for whom an initial SAH or sentinel bleed is missed tend to have poor and potentially avoidable outcomes. However, the flip side is excessive resource use either by CT scanning or invasive procedures, such as lumbar puncture. A decision aid superior to clinician judgment could add a great deal of value for this clinical scenario.

The good news first: Sensitivity for SAH was the same in the validation as it was in the derivation, effectively 100 percent. Applying the Ottawa SAH Rule, as constructed, would virtually never miss a serious outcome in an acute headache matching the inclusion criteria for the study. That said, in their pursuit of absolute sensitivity, these authors have also followed the breadcrumbs laid out by their statistical analysis to their somewhat inane conclusion: The only path to zero-miss involves evaluating virtually everyone. The specificity of their rule was 13.6 percent, capturing almost all comers in pursuit of their small handful of true positives.

This is an example of a decision aid that, after seven years and thousands of patients, likely cannot be shown to be superior to physician judgment when explicitly studied. No direct comparison was performed, but the underlying physician practice in these various studies was to investigate by either CT or lumbar puncture in between 85 percent and 90 percent of cases; the impact of this rule would be negligible. More concerning is the impact of a rule with such low specificity when used outside the narrow inclusion criteria and high prevalence of specific academic referral settings. It is possible or even likely that misuse of these criteria could lead to many more patient evaluations than by current clinical judgment without detectable advantage in patient-oriented outcomes.

A rule such as this is a prime example of why all decision aids should be tested in practice against physician judgment before their widespread use is encouraged. Given the past history of underwhelming performance of decision aids in direct comparison, this and countless other substitutions for clinician judgment should be viewed with skepticism rather than idolatry.

This should not suggest that decision aids can’t inform clinical judgment prior to formal testing, only that their limitations ought be considered at the time of utilization. Decision aids are derived and tested in unavoidably limited populations, outcomes are measured with flawed or incomplete gold standards, and the prioritization and weighting of different elements in the statistical analysis may have profound effects on the final model. Then, even in those ultimately tested against physician judgment, the same generalizability considerations persist, along with the confounding question of practice culture/environment and similarity to the clinicians involved.

The future of digital cognitive enhancement is bright, and computers may yet replace substantial portions of clinical decision making—but not today!

References

  1. Schriger DL, Elder JW, Cooper RJ. Structured clinical decision aids are seldom compared with subjective physician judgment, and are seldom superior. Ann Emerg Med. 2017;70(3):338-344.e3.
  2. Perry JJ, Sivilotti MLA, Sutherland J, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ. 2017;189(45):E1379-E1385.
  3. Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310(12):1248-1255.

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EMF Research Explores Methylene Blue for Calcium Channel Blocker Toxicity http://www.acepnow.com/article/emf-research-explores-methylene-blue-calcium-channel-blocker-toxicity/ http://www.acepnow.com/article/emf-research-explores-methylene-blue-calcium-channel-blocker-toxicity/#respond Wed, 14 Feb 2018 20:40:06 +0000 http://www.acepnow.com/?post_type=article&p=18517 Editor’s Note: This is the first installment of a continuing series highlighting researchers sponsored by the Emergency...

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Editor’s Note: This is the first installment of a continuing series highlighting researchers sponsored by the Emergency Medicine Foundation (EMF) and illustrating the impact EMF-funded research is having on emergency medicine.

Study Title: Effect of methylene blue on mortality in a porcine model of amlodipine toxicity

Authors: Jenna M. LeRoy, MD; Sean Boley, MD; K.M. Engebretsen, PharmD; Jackie Kelly, MD; Samuel J. Stellpflug, MD, FACEP

Researcher Bios

  • Dr. LeRoy is an attending emergency physician and clinical toxicologist at Regions Hospital in St. Paul, Minnesota, and assistant professor of emergency medicine at the University of Minnesota Medical School.
  • Dr. Boley is an emergency physician at United Hospital in St. Paul, Minnesota.
  • Dr. Engebretsen is a clinical pharmacist and toxicologist at Regions Hospital.
  • Dr. Kelly is a quality fellow at HealthPartners Institute for Education and Research and an emergency physician at Regions Hospital.
  • Dr. Stellpflug is an attending emergency physician and clinical toxicologist at Regions Hospital and associate professor of emergency medicine at the University of Minnesota Medical School.

Study Background

Cardiovascular medication overdose causes significant morbidity and mortality in the United States. In 2015, the National Poison Data System (NPDS) responded to more than 2.1 million exposures, with 103,339 related to cardiovascular drugs. Cardiovascular drugs were the seventh most frequently involved substance and are now rated as the NPDS top fourth category with the greatest rate of increase in exposure. Despite maximal supportive pharmacologic therapy, including vasopressor administration, high-dose insulin therapy, lipid emulsion therapy, and extracorporeal life support, there are still cases of refractory shock leading to death. In vitro studies on canine arteries exposed to amlodipine have shown that it stimulates release of nitric oxide (NO), leading to peripheral vasodilation. Amlodipine overdose could, therefore, be managed by scavenging NO. Methylene blue (MB) inhibits NO directly but also inhibits NO production by inhibiting guanylyl cyclase and endothelial NO synthase activity. We developed a porcine model of amlodipine toxicity and compared the effects of MB to traditional vasopressor therapy with norepinephrine (NE). Time to death was the primary outcome.

Study Design

The pigs were anesthetized and instrumented with monitoring devices according to previous protocols in our institution, and a pilot study was first completed to establish a lethal model of amlodipine toxicity. Each of the two groups of animals received a toxic dose of amlodipine. A continuous infusion of amlodipine with accelerating doses was given to mimic overdose and continuing gastrointestinal absorption. After 70 minutes of amlodipine infusion, each group was resuscitated with 20 mL/kg of normal saline. Animals in each group were then randomized to receive either MB or NE therapy. Hemodynamic parameters, including mean arterial pressure and cardiac output, were measured every 10 minutes.

Results

The primary outcome was time to death. Survival times were compared using a Kaplan-Meier analysis, and the two groups were compared with the log-rank test. The study was powered at 80 percent to detect a hazard ratio of 0.2 (MB versus NE), assuming a two-sided log-rank test with alpha=0.05. Nine animals per group were required for adequate power.

An interim analysis was conducted after 15 of the initially planned 18 animal protocols were completed (seven MB and eight NE). This revealed that, for the primary outcome, MB was clearly not superior to NE. Furthermore, it would be impossible to achieve a statistically significant effect for the MB hazard ratio with the addition of three pigs, regardless of the outcome. Therefore, the study was terminated early. Overall, one of seven animals (14 percent) in the MB group survived to 300 minutes compared to two of eight animals (25 percent) in the NE group. Median survival time was 100 minutes for the MB group and 177 minutes for the NE group. Survival time did not differ by group (log-rank test P=0.29), but there was a nonsignificant trend toward longer survival in the NE group.

Projected Impact

Our data contribute to a growing body of literature on usage of methylene blue in toxin-induced shock. We hope that this will encourage more research in the field as it is still unclear where this antidote fits in the management of patients.


Dr. LeRoy is an attending emergency physician and clinical toxicologist at Regions Hospital in St. Paul, Minnesota, and assistant professor of emergency medicine at the University of Minnesota Medical School.

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Takeda’s Zika Vaccine Gets U.S. FDA’s ‘Fast Track’ Status http://www.acepnow.com/article/takedas-zika-vaccine-gets-u-s-fdas-fast-track-status/ http://www.acepnow.com/article/takedas-zika-vaccine-gets-u-s-fdas-fast-track-status/#respond Wed, 14 Feb 2018 20:15:42 +0000 http://www.acepnow.com/?post_type=article&p=18515 Japan’s Takeda Pharmaceutical Co Ltd said on Monday the U.S. Food and Drug Administration (FDA) had granted...

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Japan’s Takeda Pharmaceutical Co Ltd said on Monday the U.S. Food and Drug Administration (FDA) had granted “fast track” status to its vaccine for the mosquito-borne Zika virus, which erupted as a major public hazard in Brazil three years ago.

The drug, TAK-426, is currently being tested on 240 patients between the ages of 18 and 49 and is in early stages of development.

The virus might be responsible for an increase in birth defects in the United States and its territories, the U.S. Centers for Disease Control and Prevention said in a report last week.

The Zika outbreak was declared an international public health emergency by the World Health Organization in 2016 due to linkages found between the virus and severe birth defects.

The FDA’s “fast track” designation aims to facilitate the development and expedite the review process for certain drugs and vaccines for serious conditions with unmet medical need.

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FDA Asks Drugmakers to Limit Amount of Opioid Drug in Packaging http://www.acepnow.com/article/fda-asks-drugmakers-limit-amount-opioid-drug-packaging/ http://www.acepnow.com/article/fda-asks-drugmakers-limit-amount-opioid-drug-packaging/#respond Wed, 14 Feb 2018 20:05:04 +0000 http://www.acepnow.com/?post_type=article&p=18513 The U.S. Food and Drug Administration is asking manufacturers of a common opioid medicine to change the...

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The U.S. Food and Drug Administration is asking manufacturers of a common opioid medicine to change the way the drug is packaged, as part of efforts to deter its abuse amid an opioid epidemic in the United States.

The FDA said on Jan. 30, 2018, it sent letters to manufacturers of diarrhea medicine loperamide, asking them to ensure that packages contain only a limited amount of the drug that is appropriate for use for short-term diarrhea.

The agency wants to eliminate the large bottles in which loperamide is often sold because the abuse of the drug requires such large quantities.

The FDA is also asking online retailers which sell loperamide to take voluntary steps to address the issue. It is also influencing doctors to prescribe shorter-duration opioids.
The actions come amid reports of serious heart problems and death in patients who have taken higher-than-recommended doses of the drug or have misused it, the FDA said.
They are also part of the agency’s efforts to reduce patients’ exposure to opioids, which killed more than 42,000 Americans in 2016, according to estimates from the Centers for Disease Control and Prevention.

Loperamide is used to treat short-term symptoms of diarrhea, including Traveler’s diarrhea, a digestive tract disorder that commonly causes loose stools and abdominal cramps.

The drug is sold under the brand name Imodium A-D, as store brands and as generics. Imodium is marketed by Johnson & Johnson in the United States.

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Myths in Emergency Medicine: Kidney Stones, Beyond the Pain http://www.acepnow.com/article/myths-emergency-medicine-kidney-stones-beyond-pain/ http://www.acepnow.com/article/myths-emergency-medicine-kidney-stones-beyond-pain/#respond Tue, 13 Feb 2018 19:00:08 +0000 http://www.acepnow.com/?post_type=article&p=18506 The momentum of kidney stone patient “expulsion” from the emergency department has never been greater. Big stone?...

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The momentum of kidney stone patient “expulsion” from the emergency department has never been greater. Big stone? No problem. Obstruction? No problem. Infection? That’s the problem. Some of these patients may require admission.

A recent interesting malpractice claims trend has prompted a reassessment of outpatient management of nephrolithiasis. Females with an active ureteral stone with obstruction and, most important, possible urinary tract infection (UTI) have returned with pyelonephritis and sepsis, suffering horrific outcomes. Urinary symptoms, other than those associated with acute ureterolithiasis, are often absent in these patients.

Although few recommendations deserve inclusion of an “always” or a “never,” this trend at least deserves some consideration in our approach to certain cases.

In England and Wales, 91 percent of deaths from nephrolithiasis were associated with kidney and ureteral stones, compared to lower tract stones, which accounted for 7.9 percent of deaths. Although the raw numbers aren’t alarming—mean 9.4 deaths per year from ureteric stones (141 deaths total) and 130.3 deaths per year from urolithiasis (1,954 deaths total) identified between 1999 and 2013—their report of increasing trends in developed nations is concerning. Although men had a higher incidence (1.3:1) of stones compared to women, mortality was significantly higher in females (1.5:1). Equally worrisome, urosepsis accounts for 25 percent of adult sepsis cases.1

“This too shall pass,” a quote dating back to 1839, fits well with regard to stone size.2

It has been taught that stones ≥5 mm are unlikely to pass spontaneously. That’s a reasonable guideline, but what difference does it really make? If patients are pain-free or their pain can be controlled with oral analgesics, there are no indications for admission (eg, pyelonephritis, solitary kidney, etc.), and follow-up is available, then size isn’t critical for the disposition decision. Jendeberg et al reported multiple CT-related variables that may predict stone passage.3 Although limited by the study’s retrospective design and nonstandardized follow-up, their conclusion suggests our 5 mm line in the sand is less than clear. “The spontaneous passage rate in 20 weeks was 312 out of 392 stones, 98% in 0–2 mm, 98% in 3 mm, 81% in 4 mm, 65% in 5 mm, 33% in 6 mm and 9% in ≥6.5 mm wide stones.”3 Stone size appears to be relegated to an academic discussion with limited relevance to emergency medicine.

Hydronephrosis is practically synonymous with obstruction and is expected with active ureteral stones. However, an active stone that is unlikely to pass may prolong the duration of associated ureteral obstruction.3 In the context of possible infection, obstruction is important.

Uncomplicated UTIs can almost universally be treated without hospitalization. UTIs in the context of nephrolithiasis with obstruction, however, are complicated. Appropriate diagnosis is critical.

Although admission may be unnecessary, noting the potential for poor outcomes, even with a seemingly benign presentation, mandates something more than the standard approach for those without possible UTI. Thus, initiation of antimicrobials, phone consultation, confirmed close follow-up, and, in some cases, admission, are all reasonable considerations.

The limitations of nitrite, leukocyte esterase, and the presence white blood cells (>5/hpf) via dipstick or formal urinalysis may lead to dismissing positive findings. In asymptomatic patients without a stone, a wait-and-see approach is appropriate for nondefinitive findings. However, with an obstructive stone, any one being positive should prompt recognition in the medical record, the ordering of a culture, and consideration of the above strategies.
Watch the pH. Some organisms are urease-producing, reducing urea, which has an antibacterial effect, and will increase ammonia levels.4 This effect has been found in more than 200 bacterial species, including Ureaplasma urealyticum, Proteus, Klebsiella, and Pseudomonas.4 The alkaline environment prompts formation of struvite-magnesium ammonium phosphate (infected stones) and apatite-calcium phosphate stones.5,6 Also, staghorn calculi are frequently composed of these two types.7 UTI may be causative, not an incidental finding, with nephrolithiasis.5,6,7 Further, some suggest greater mortality from struvite and staghorn stones, as they cannot be treated with antimicrobials alone.6
Being mindful of possible infection associated with acute nephrolithiasis may improve outcomes and will definitely reduce your professional liability risk.

References

  1. Kum F, Mahmalji W, Hale J, et al. Do stones still kill? An analysis of death from stone disease 1999-2013 in England and Wales. BJU Int. 2016;118(1):140-144.
  2. Keyes R. The Quote Verifier: Who Said What, Where, and When. New York, NY: St. Martin’s Press; 2006:159-160.
  3. Jendeberg J, Geijer H, Alshamari M, et al. Size matters: the width and location of a ureteral stone accurately predict the chance of spontaneous passageEur Radiol. 2017;27(11):4775-4785.
  4. McLean, Nickel JC, Cheng KJ, et al. The ecology and pathogenicity of urease-producing bacteria in the urinary tract. Crit Rev Microbiol. 1988;16(1):37-79.
  5. McLean, Nickel JC, Noakes VC, et al. An in vitro ultrastructural study of infectious kidney stone genesis. Infect Immun. 1985;49(3):805-811.
  6. Nickel JC, Costerton JW, McLean RJ, et al. Bacterial biofilms: influence on the pathogenesis, diagnosis and treatment of urinary tract infections. J Antimicrob Chemother. 1994;33(Suppl A):31-41.
  7. Zhao P. Staghorn calculi in a woman with recurrent urinary tract infections: NYU case of the month, December 2016Rev Urol. 2016;18(4):237-238.

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ACEP Leadership Addresses Sedation, Prudent Layperson Standard, and More http://www.acepnow.com/article/acep-leadership-addresses-sedation-prudent-layperson-standard/ http://www.acepnow.com/article/acep-leadership-addresses-sedation-prudent-layperson-standard/#respond Mon, 12 Feb 2018 22:57:49 +0000 http://www.acepnow.com/?post_type=article&p=18502 ACEP President Paul Kivela, MD, MBA, FACEP, President-Elect John Rogers, MD, FACEP, and ACEP staff met with...

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ACEP President Paul Kivela, MD, MBA, FACEP, President-Elect John Rogers, MD, FACEP, and ACEP staff met with leaders of the American Society of Anesthesiologists to discuss their sedation polices and potential impact on emergency medicine practice. They also discussed collaboration and strategies to ensure reasonable out-of-network reimbursement.

In late December, Dr. Rogers and ACEP Associate Executive Director for Public Affairs Laura Wooster met with representatives of Anthem to discuss Anthem’s policy to deny payment for patient visits to the emergency department in several states, which ACEP contends is in violation of federal and state law protecting patients, according to the prudent layperson standard.

In December, ACEP’s Board held its annual strategic planning meeting. The Board discussed many issues that impact the specialty, including ways to overcome challenges to fair reimbursement, how to enhance ACEP’s engagement with members on social media, quality measures and CEDR, the care of patients with mental health disorders, and how to seek improved relations with other emergency medicine organizations.

For a monthly rundown of what the ACEP leadership is doing to affect emergency medicine for you and your patients, visit acep.org/leadershipreport.

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Tips on MIPS http://www.acepnow.com/article/tips-on-mips/ http://www.acepnow.com/article/tips-on-mips/#respond Mon, 12 Feb 2018 22:48:56 +0000 http://www.acepnow.com/?post_type=article&p=18497 Want to know more about reporting under the Merit-Based Incentive Payment System (MIPS)? This is for you:...

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Want to know more about reporting under the Merit-Based Incentive Payment System (MIPS)? This is for you: an in-depth review of the steps and process involved using the Clinical Emergency Data Registry (CEDR) for group or individual 2018 MIPS reporting. Topics for this webinar will include selection of reportable measures, advancing care information data entry, and improvement activity reporting through CEDR. The webinar will be March 13, 2018 at 1 p.m. CDT. Register now at acep.org/CEDR.

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2018 Awards and Board of Directors Nominations Now Open http://www.acepnow.com/article/2018-awards-board-directors-nominations-now-open/ http://www.acepnow.com/article/2018-awards-board-directors-nominations-now-open/#respond Mon, 12 Feb 2018 02:16:36 +0000 http://www.acepnow.com/?post_type=article&p=18495 Know someone who deserves to be recognized for their emergency medicine achievements? The ACEP awards program has...

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Know someone who deserves to be recognized for their emergency medicine achievements? The ACEP awards program has been developed for one reason: to recognize leadership and excellence. The program provides an opportunity to recognize our members for significant professional contributions as well as service to the College. All entries must be submitted by April 2, 2018, to be considered by the Awards Committee. Visit acep.org/awardnomination to nominate today.

The ACEP Nominating Committee is now accepting individual, chapter, and section recommendations for Board of Directors candidates. Board candidates must be highly motivated, their membership in good standing, and involved in ACEP national and chapter activities. For complete requirements and submission information, visit acep.org/leadershipnominations.

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Emergency Physician and Victim Share Experiences from Las Vegas Mass Shooting http://www.acepnow.com/article/emergency-physician-victim-share-experiences-las-vegas-mass-shooting/ http://www.acepnow.com/article/emergency-physician-victim-share-experiences-las-vegas-mass-shooting/#respond Mon, 12 Feb 2018 01:54:37 +0000 http://www.acepnow.com/?post_type=article&p=18488 On Oct. 1, 2017, attendees of the Route 91 Harvest country music festival in Las Vegas were...

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First responders to the mass shooting on the Las Vegas Strip. Credit: STAR MAX/IPX

On Oct. 1, 2017, attendees of the Route 91 Harvest country music festival in Las Vegas were enjoying the event’s closing performance by Jason Aldean when tragedy struck. A single gunman opened fire on the crowd from a room in the nearby Mandalay Bay Resort and Casino, injuring 851 people and killing 58. The victims were transported by private vehicle, taxi, and ambulance to nearby hospitals, including Sunrise Hospital & Medical Center, where Scott Scherr, MD, medical director of the emergency department, and his colleagues prepared to treat the injured.

ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Scherr and Jeannine Ruggeiro, a 28-year-old social work graduate student from Sonoma County, California, who was one of the shooting victims that night, to discuss their experiences in the aftermath of the mass shooting. Here is Part 1 of their conversation. Part 2 will appear in the March issue.

KK: Scott, we’ll just touch base about this event Oct. 1 at the Harvest music festival in Las Vegas. You’re the medical director at Sunrise. How many patients did you receive that night?

Dr. Scherr

Dr. Scherr

SS: We saw 215 patients, and all 215 patients were seen within about 90 minutes. The first patient arrived by private vehicle 20 minutes after the incident started.

KK: Did you have the sense what the volume of patients would be or that there was even an event going on?

SS: I was at home getting ready for bed when I got the calls and the text messages, so I just hurried up and got dressed. I was listening to the radio on the way in and heard a report of an active shooter on the Strip with two known fatalities and multiple injuries. I wasn’t expecting this type of magnitude when I showed up 45 minutes after the incident started and saw the ambulance bay full of private vehicles, trucks, Ubers, and taxis.

KK: How were you able to coordinate all of that traffic in the ambulance bay?

Jeannine Ruggeiro

Jeannine Ruggeiro

SS: Fortunately, Dr. Kevin Menes is a SWAT medic. He was able to go to his car, get his radio, and listen to the police chatter. By the time I got there, he had all the gurneys, wheelchairs, and frontline staff actually sitting and waiting in the ambulance bay for the first patients to arrive.

KK: Did you do any initial triage outside of the emergency department, or did you bring everybody inside to do that?

SS: Everybody was brought inside. We were fortunate that this was a Sunday night in Las Vegas. The ED volume was not like it would be on a Monday or Tuesday night, so we were able to put our active patients in certain areas to make room for the patients that were coming in. Initially, the MCI [mass casualty incident] triage was done by a physician. However, we needed physicians in the back to take care of the sicker patients, so we passed that on to one of the nurses out there to coordinate the MCI triage. A lot of things that I’m going to learn, I’m going to learn from Jeannine, from the patient’s perspective.

Station 1 was the area where we took care of all our “red” patients. Those were our most unstable patients with the most life-threatening injuries. Station 2 and Station 4 were for what we call our “yellow” or our “immediate” patients to resuscitate them and stabilize them there. Then we utilized our ambulatory care areas, our pediatric emergency department, and our PAC-U [post-anesthesia care unit] space [as Station 3] for what we call our “green” patients, which is kind of our “walking wounded.” We had that pretty well dialed in when the first patients started to arrive.

KK: Can you give us a sense of the spectrum of injuries that you saw?

SS: Most severe were gunshot wounds to the chest, abdomen, and also to the head.

KK: I have to credit you and others for your disaster preparedness plan and making sure everybody was ready to go. Do you think that plan was adequate?

The Sunrise Hospital & Medical Center emergency department after caring for the victims of the Oct. 1 mass shooting in Las Vegas.

The Sunrise Hospital & Medical Center emergency department after caring for the victims of the Oct. 1 mass shooting in Las Vegas.
Sunrise Hospital & Medical Center/Scott Scherr

SS: It was from an organizational standpoint, but there were a lot of lessons learned. We’ve practiced MCIs and even had a few MCIs, but nothing to this scale, so there are certain things that we ran out of. We ran out chest tubes and laryngoscopes. We ran out of ventilators at one point. We ended up having to put two patients on the same ventilator at one point. Sunrise is part of a three-hospital system, so we were able to commandeer level 1 transfusers, chest tubes, laryngoscopes, and blood products from our area hospitals in a matter of minutes.

KK: What did you do in those cases where you realized you were ready to put the chest tube in and you didn’t have any more chest tubes? What do you do?

SS: We utilized endotracheal tubes to substitute as a chest tube until we could get more chest tubes.

KK: That’s impressive. And two patients on one ventilator?

SS: There’s data out there from case studies. If they’re like-sized, you just double the tidal volume and separate the ventilator by an H-tube or a T-tube. Luckily, we only had to do that one time, and it was only for a matter of minutes until we got another ventilator.

KK: Wow, but what a great solution. Who came up with that idea?

SS: Actually, Dr. Menez did. That was one of his patients. We’ve read about it, and the respiratory therapist knew exactly what equipment to provide.

KK: You mentioned earlier that you are really trying to get your arms around the data of this whole event. Can you tell us a little bit about what you know already from that assessment?

SS: A lot of things, very simple stuff. Registration got completely overwhelmed, and you can’t do anything treatment-wise on the patient or order any medications on the patient without proper identification of the patient. When you see 215 patients in 90 minutes, to get them into the computer in an accurate fashion, that was really difficult. We’re working on ways to have a more rapid intake model when it comes to patient identification.

Communication with incident command is really good, but the footprint of the ER grew from a 45-bed ER and multiplied by roughly four times as we took over the PAC-U space and the pediatric ER space and various other spaces on the ground floor of the hospital. It made my job difficult to communicate with the physicians in each station on what they needed and the status of the patients in those stations.

Another issue was obtaining radiology interpretations. When an X-ray is taken, it’s taken electronically and needs to be verified by the technologist before the radiologist could interpret it. We actually had the radiologist follow the portable X-ray machine around and provide preliminary reads to us verbally, or they would write them on the patient’s gurney or on the patients themselves. We had real-time reads.

KK: Did you get anything documented on these patients in a formal fashion at all?

SS: We did initially, but the documentation was sparse. We had 18 of our scribes show up that night, so we were able to do a pretty good job documenting later once the patients were verified and put in the proper treatment areas.

KK: I would think that’s one of the first things that is going to go by the wayside. Take care of the patients and document what you can, if you can. With 200-plus patients, how much time did it take to process and take care of all of them?

SS: By probably six o’clock in the morning, everybody had been seen and taken care of. By eight or nine o’clock in the morning, we had pretty much the entire emergency department cleared of anybody that was involved in the incident.

KK: That’s an impressive piece of work, Scott, and I can’t thank you enough for the service you provided to prepare your team and, most important, to care for those 215 victims. What a great demonstration of the impact that emergency physicians and emergency medicine can provide for a community.

SS: The response that we got, not only our ER team but from so many others, was amazing. We had 20 physicians and nurse practitioners show up to the emergency department that night. We had pediatric emergency department doctors and nurses taking care of adult patients on their side [of the emergency department] and then over 100 physicians, including pediatric surgeons, handling the sickest patients. Over 200 surgeons and additional staff responded as well.

KK: What your team, hospital, and community did in such short order is nothing less than heroic. As unfortunate as this was, I’m sure lessons can be learned from this horrific event. What we don’t hear much about is the patient’s perspective. From a humanistic perspective, what are their experiences like? So Jeannine is with us, and she’s been kind enough to share her thoughts with us. Scott, did you take care of Jeannine?

SS: I didn’t directly take care of her. She was in Station 2. The reason I know that is I had a call from one of my high school friends stating that the fiancée of one of the guys that he works with in the police department was shot and was injured, so I asked the age of the patient and the injuries and I said, “Well, that sounds like somebody who was in Station 2 that one of my docs, Dr. English, took care of,” and it ended up being Jeannine. About two days later, I was able to visit Jeannine in the hospital.

KK: Jeannine, could you tell us a little bit about your evening before this whole thing happened?

JR: It was the third day of the music festival and the last performer of the night, Jason Aldean. I was toward the front of the stage on the right-hand side, on the Mandalay Bay side, with two of my girlfriends. We were dancing, laughing, singing, had drinks, just like pretty much everyone else in the crowd, when the shooting started. When it first started, none of us knew what was going on. Everybody in the crowd said, “Oh, maybe it’s fireworks. Maybe it’s a blown amp.” Jason Aldean was still performing at that point, and then the shooting began again at a faster pace. Everyone dropped to the ground. Jason Aldean went off the stage. People were confused; people were screaming. I immediately just had this feeling like, “How do I get out of here?” Then there was a break in the shooting for a couple moments. We got up to run, and it was at that time I was shot in my back and collapsed to the ground.

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ACEP Now Celebrates 50 Years of Emergency Medical Care http://www.acepnow.com/article/acep-now-celebrates-50-years-emergency-medical-care/ http://www.acepnow.com/article/acep-now-celebrates-50-years-emergency-medical-care/#respond Sun, 11 Feb 2018 20:51:21 +0000 http://www.acepnow.com/?post_type=article&p=18484 What we’ve accomplished in the first 50 years begs the question, how will emergency medical care look...

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What we’ve accomplished in the first 50 years begs the question, how will emergency medical care look 50 years from now? A bright future is illuminated by knowledge of the past. As part of the celebration of our specialty’s 50th anniversary, ACEP Now will provide a series of articles discussing the timeline of many critical aspects of emergency medicine.

What seems commonplace today may not have been so clear back then, and many stops along the way have proved ineffective or even harmful, but it’s all part of the evolution of emergency medicine. What milestones were reached? Who was involved? Dead ends? Plenty of those. Today’s emergency physician has to ask, how could they practice back then? Many from that era might say the same about today’s emergency medicine.

We intend to cover topics such as stroke, acute coronary syndrome, trauma care, resuscitation, toxicology, infectious disease, airway management, and many more. Illustrating the issues of the times is a compilation of covers and advertisements from the Journal of the American College of Emergency Physicians (JACEP), now known as the Annals of Emergency Medicine.

Stroke: In the 1960s, hypertension was identified as a risk factor for stroke, and in the 1970s, aspirin made a big splash along with the advent of the CT scanner.

Trauma: Although the concept of pneumatic anti-shock garments was introduced in 1903, NASA claimed credit for the development of medical anti-shock trousers (MAST) in the 1960s. MAST entered the medical scene during the Vietnam War and were deemed essential for all ambulances to carry by the American College of Surgeons Committee on Trauma in 1977.

Sepsis: Lactate was first introduced in 1964? What took knowledge translation so long? In 1954, corticosteroids emerged as a treatment option for severe infections, and it took the next 50-plus years to prove that they didn’t work.

Toxicology: In the late 1970s and early 1980s, ipecac was all the rage! Home? Hospital? It didn’t matter—give it! It’s hard to imagine the sheer volume of emesis that must have been produced until this approach to gastric decontamination fell out of favor due to aspiration, Mallory-Weiss tears, bronchospasm, pneumomediastinum, and other complications.

Acute Coronary Syndrome: In the early 1970s, the World Health Organization defined a myocardial infarction as any two of the following three: 1) chest pain, 2) development of Q waves on an ECG, and 3) increase in cardiac enzymes (combination of total creatine phosphokinase, creatine phosphokinase-MB, aspartate aminotransferase, and lactate dehydrogenase).

Public Policy: In 1966, the National Academy of Sciences published a white paper, “Accidental Death and Disability, the Neglected Disease of Modern Society,” which seems to coincide with the early recognition of the need for the specialty of emergency medicine.

It is truly amazing to consider how far we’ve come in a relatively short period. Although emergency medicine is young compared to many other specialties, our roots are well established, and we have earned our place in the history of the house of medicine through evidence-based contributions, public health advancements, and public policy initiatives. We look forward to helping illustrate emergency medicine’s wonderful history in the coming months.

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