ACEP NowACEP Now https://www.acepnow.com Mon, 18 Nov 2019 00:09:31 +0000 en-US hourly 1 https://wordpress.org/?v=5.3 Chest Tubes: Pearls and Pitfalls https://www.acepnow.com/article/chest-tubes-pearls-and-pitfalls/ https://www.acepnow.com/article/chest-tubes-pearls-and-pitfalls/#respond Tue, 05 Nov 2019 14:17:40 +0000 https://www.acepnow.com/?post_type=article&p=22331 When U.S. Air Force Maj. Regan Lyon, MD, FACEP, was in medical school and residency, she nearly...

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When U.S. Air Force Maj. Regan Lyon, MD, FACEP, was in medical school and residency, she nearly always inserted chest tubes using large-bore catheters. But, increasingly, literature and experience has shown her that small-bore catheters can be just as effective for most patients.

Now it’s just a matter of getting that word out to other emergency physicians, Dr. Lyon said during her ACEP19 presentation, “Chest Tubes – Pearls and Pitfalls.”

“We were taught large bore all the time,” Dr. Lyon said. “I put in maybe one pigtail (catheter) in my whole residency because it just wasn’t utilized. And so a lot of people who aren’t necessarily reading up on the data may still be doing that. But we can save our patients a lot of pain, and even some time for us.”

Dr. Lyon aid that for small, spontaneous, stable pneumothoraces, she recommends putting patients on oxygen and reviewing before immediately moving to a chest tube insertion.

“For simple pneumothoraces alone – spontaneous, secondary, traumatic, etc.  – you could probably just use a small-bore catheter,” she said. “The only thing you probably need a large bore chest tube anymore is an empyema and some hemothoraces.”

Dr. Lyon said that reducing pain for patients is a major factor in considering which size chest tube to select.

“Pain management, however you choose it, is going to be important,” she said. “This is not a benign procedure for a patient, especially an awake patient.”

Aside from tube-size selection, Dr. Lyon suggested emergency physicians consider using ultrasound to guide insertion, as that helps lessen discomfort to patients. In addition, doctors need to think through what type of pain control they prefer.

“Local infiltration of lidocaine or some kind of anesthetic over the rib should probably always be used, if you have the time to be able to do it,” Dr. Lyon added.

Dr. Lyon said she often will use a systemic approach – ketamine or fentanyl, for example – but added that emergency physicians need to consider how long the patient has been exhibiting symptoms. If a patient’s injury occurred too long a time before the administration of pain control, there could be respiratory complications.

A middle ground between treatments such as lidocaine and fentanyl would be a regional technique, such as a paravertebral block. Dr. Lyon joked with the audience that while those blocks can take a long time, they are effective.

“If you have the skills and you’ve ben trained in that, absolutely,” she said. “It does work. I make fun of the anesthesiologists, but it absolutely does work.”

Dr. Lyon said that there are reasons to use large-bore catheters, but emergency physicians need to make sure they think through those cases. In many cases, a quick consultation with surgeons may help steer the decision.

“The only thing you probably need a large bore chest tube anymore is an empyema and some hemothoraces,” she said. “The literature, especially the trauma literature, is starting to suggest that even in traumatic hemothoraces we can use pigtail catheters and small-bore chest tubes.”

Richard Quinn is a freelance writer from New Jersey.

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The Death of Normal Saline: IV Fluids in 2019 https://www.acepnow.com/article/the-death-of-normal-saline-iv-fluids-in-2019/ https://www.acepnow.com/article/the-death-of-normal-saline-iv-fluids-in-2019/#respond Tue, 05 Nov 2019 14:13:58 +0000 https://www.acepnow.com/?post_type=article&p=22329 Intravenous saline has been a go-to for physicians since 30 years before the Civil War started. Emergency...

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Intravenous saline has been a go-to for physicians since 30 years before the Civil War started. Emergency physician and intensivist Nicholas Johnson, MD, of University of Washington’s Harborview Medical Center in Seattle, thinks it’s about time that changed.

So his ACEP19 session, “The Death of Normal Saline: IV Fluids in 2019,” was an impassioned sales pitch on the value of using balanced fluids such as Lactated Ringer’s.

“There’s no difference in cost, there’s definitely no harm in using balanced solutions and there’s a fairly large and growing body of data showing that saline is associated with lots of different types of harms,” Dr. Johnson said. “Metabolic abnormalities, acute kidney injury and maybe even mortality… all of the data is sort of pointing us in one direction.”

Dr. Johnson’s talk focused on last year’s SMART trial, from Vanderbilt University Medical Center in Nashville, Tennessee. The review found rates of major kidney events at 30 days out were roughly 1% lower with balanced crystalloids versus saline. A companion study of non-critically ill patients showed similar results.

“People have looked at this trial and come away with two different conclusions, depending on their prior beliefs,” Dr. Johnson said. “Some people said, ‘A 1% difference in positive outcomes?  Big deal. Is this really something that should be practice changing?’ And other people have said it’s really hard to conduct a critical-care trial that shows any difference – so any difference in meaningful.”

Dr. Johnson, clearly in the latter camp, said there are cases where saline may be better than a balanced solution, including patients where drug compatibility is a concern or potential issues with brain injuries or hyperkalemia. He also noted that given the dichotomous views on the efficacy of balanced solutions, he doesn’t expect emergency physicians to abandon saline en masse.

Still, given his views on the benefits of balanced solutions including Lactated Ringer’s and Plasma-Lyte A, Dr. Jonhson suggests practice changes to encourage their use. The bedside carts he uses have been reorganized to put Lactated Ringer’s on top of saline, so physicians don’t just reach for saline out of routine. In addition, all of the department’s word sets have been updated to put balanced solutions over saline.

“At least among the group that I work with, this is something that evolved over many ears and eventually the culture changes,” Dr. Johnson said. “But culture change is hard. We can make it easier for people by changing how things are stored in the hospital and changing how things are listed on the electronic medical record. And those have been shown to change behavior in various ways, but culture change is one of the hardest things that we do in medicine.”

Dr. Johnson is hopeful that more studies will be done on the value of balanced solutions versus saline.

“Translating evidence to practice takes 5-7 years on average,” he said. “And so this is one of those things that I think were just going to have to wait for a little bit. Keep talking about it, and keep educating people.”

Richard Quinn is a freelance writer from New Jersey.

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Emergency Medicine Foundation Announces 2019–2020 Grantees https://www.acepnow.com/article/emergency-medicine-foundation-announces-2019-2020-grantees/ https://www.acepnow.com/article/emergency-medicine-foundation-announces-2019-2020-grantees/#respond Tue, 05 Nov 2019 13:57:41 +0000 https://www.acepnow.com/?post_type=article&p=22323 Mid-Career Research Development Ryan McCormack, MD, MS NYU Langone Health Rapid Induction of Buprenorphine in the Emergency...

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Mid-Career Research Development

Ryan McCormack, MD, MS
NYU Langone Health
Rapid Induction of Buprenorphine in the Emergency Department
$248,799


VA Fellow to Faculty Career

Matthew Augustine, MD, MS
Icahn School of Medicine at Mount Sinai, James J Peter VA Medical Center
Using Regional Information Exchanges to Understand VHA and Non-VHA ED Utilization
$200,000


EMF/AFFIRM Early Career Research Development

Kristen Mueller, MD
Washington University in St. Louis
Firearm Injuries and Recidivism at St. Louis Level I Trauma Hospitals
$150,000


Pilot Research

Dowin Boatright, MD, MBA, MHS
Yale University
Racial/Ethnic Differences in Emergency Medicine Residency Milestone Evaluation
$50,000


EMF/CORD Emergency Medicine Education Research

Jeffrey Riddell, MD
Keck School of Medicine of the University of Southern California
A Qualitative Exploration of Trust and Credibility Judgments in Educational Podcasts
$25,000


EMF/CORD Emergency Medicine Education Starter

Cynthia Peng, MD
Stanford University
Use of an Online Simulation Platform for Assessing Entrustable Professional Activities During Transition into Residency
$10,000

 

Michael Gottlieb, MD
Rush University Medical Center
The Impact of Driving on Podcast Knowledge Acquisition and Retention Among Emergency Medicine Resident Physicians
$10,000


EMF/Medical Toxicology Foundation

Daniel Nogee, MD
Yale New Haven Hospital
Machine Learning Enhanced Diagnosis of Toxic Exposures
$10,000


EMF/AFFIRM Medical Student Research

Henry Schwimmer, BA
Emory University School of Medicine Rural Emergency Department Firearm Assessment, Screening, and Treatment (FAST) Trial
$5,000


Emergency Medicine Basic Research Skills (EMBRS)

Kara B. Goddard, PharmD, BCPS
University of Missouri
Expected versus actual concentrations of propofol and ketamine during procedural sedation in the emergency department
$5,000


EMF/EMRA Resident Research

Dana Im, MD, MPP, MPhil
Massachusetts General Hospital and Brigham and Women’s Hospital
Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies
$7,770

 

Patrick Tyler, MD
Beth Israel Deaconess Medical Center
Thromboelastography to Assess Coagulopathy and Glycocalyx Degradation in Sepsis
$10,000

 

Nicklaus Ashburn, MD
Wake Forest School of Medicine
Integrating Cutting-Edge Biomarkers into the Emergency Chest Pain Evaluation (ICE-CP)
$10,000

 

Avi Baehr, MD
University of Colorado, Denver
Adverse Events After ED Discharge for Conditions with High Variability in Discharges
$10,000

 

Jesse Wrenn, MD, PhD
Vanderbilt University
The Scanned Document Problem: Using Paper Records in Emergency Care
$10,000


EMF/SAEMF Medical Student Research

Kirstin Woody Scott, MPhil, PhD
University of Washington
Assessing Financial Risk Among Uninsured Patients Seeking Emergency Medical Care
$5,000

 

Tejeshwar Bawa, BS
Wayne State University
Effective Nutritional Analyses as a Predictive Utility for 30-Day Cardiac Recovery
$5,000

 

Matthew Lippi, BS
University of Colorado School of Medicine
National Trends and Outcomes of Sepsis Readmission
$5,000

 

Austin Jones, BA, BS
Tulane University
Evaluating Hepatitis C Linkage to Care: Emergency Department Versus Community Clinics
$5,000

 

Alexandra Flessel, BS
Wayne State University
Investigating Psychosocial Factors, Health Behaviors, and Diabetic Control in Emergency Department Patients
$5,000


EMF/NAEMSP EMS Research

David Hostler, PhD, EMT-P and Brian Clemency, DO, MBA, FACEP
University at Buffalo
Understanding the Nutrition Practices of Dayshift and Nightshift EMS Workers
$5,000

 

Jason McMullan, MD, MS, FAEMS and Joshua Borkosky, NRP
University of Cincinnati
Paramedic Attitudes to Obtaining Informed Consent for Prehospital Research Trials
$5,000

 

Gregory Faris, MD; David Rayburn, MD, MPH; and Leon Bell, EMT-P, MS 
Indiana University School of Medicine, Indianapolis Emergency Medical Service
Utilizing Simulation to Improve Pediatric Prehospital Medical Care
$3,750


2020–2021 EMF Grant Opportunities Announced

The application deadline is February 7, 2020. RFP’s are available now at EMFoundation.org/ApplyForAGrant. Contact Cynthia Singh with questions.

New Grants

  • Nasal High Flow Therapy for Respiratory Compromised Patients in the Emergency Department: $180,000 (1)
  • Diagnostics Research: $10,000 (1)
  • Reducing Burnout Through Emergency Department Design: $40,000 (1)
  • Better Prescribing Better Treatment Impact Research: $15,000 (1)

EMF Funded Grants

  • Mid-Career Research Development: $250,000 (1)
  • Early Career Research Development: $150,000 (1)
  • Pilot Research: $50,000 (1)

Partner Grants

  • EMF/ENAF/AFFIRM Research Grant: $75,000 (1)
  • EMF/CORD Education Research: $25,000 (2)
  • EMF/CORD Education Research Starter: $10,000 (2)
  • EMF/EMRA Resident: $10,000 (4)
  • EMF/EMRA/AFFIRM Resident: $12,000 (1)
  • EMF/Medical Toxicology Foundation: $10,000 (1)
  • EMF/SAEMF Medical Student: $5,000 (4)
  • EMF/NAEMSP EMS Research: $5,000 (3)

Number in parenthesis indicates number of grant awards available

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A New Approach to Dizzy Patients https://www.acepnow.com/article/a-new-approach-to-dizzy-patients/ https://www.acepnow.com/article/a-new-approach-to-dizzy-patients/#respond Tue, 29 Oct 2019 19:51:24 +0000 https://www.acepnow.com/?post_type=article&p=22315 Matthew Siket, MD, MS, FACEP, used his ACEP19 session on dizziness to demystify the symptom’s diagnosis and...

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Matthew Siket, MD, MS, FACEP, used his ACEP19 session on dizziness to demystify the symptom’s diagnosis and treatment. But first, he asked a room full of emergency physicians to raise their hands if they hated those symptoms.

Martin Springer, MD, FACEP, raised his hand.

So did nearly every other doc in the room.

“I think we all do,” said Dr. Springer, who practices emergency medicine in the U.S. and Beijing. “And I know that there are these new exams people are doing. I’ve tried doing it and obviously now, according to this lecture, it’s clear to me that I chose the wrong patients to do it on.”

Welcome to “Why ‘What Do You Mean Dizzy?’ Should Not Be the First Question You Ask of a Dizzy Patient,” led by Dr. Siket, of Robert Larner College of Medicine at the University of Vermont.

Perhaps Dr. Siket’s best advice for frustrated emergency physicians was the course title. He told doctors to stop kicking off exams by asking the age-old question of whether the presenting dizziness felt like lightheadedness or vertigo.

“Does that make any sense?” Dr. Siket asked. Telling a patient, “’Come on, lady. You’ve got to commit. Is this lightheadedness or vertigo? Question 1, I’m not proceeding until you give me that answer.’ … Don’t box in your patients. Don’t make them commit with that first question that’s just setting yourself up for diagnosis error.”

Dr. Siket noted that while dizziness is most often benign, it can have deadly underlying causes that are often missed.

“It’s awfully difficult to be diagnostically subtle and really hone in on these patients which present with mild or subtle deficits, if any at all, when our workplace environment is chaotic,” Dr. Siket said.

Dr. Siket’s clinical pearls focused on using a systematic approach. He urged the use of the ATTEST mnemonic (Associated symptoms, Timing, Triggers, Exam, Signs, Testing) to standardize that approach. He suggested physicians categorize vestibular syndromes by type to guide their workups. He added that both the presence and the type of nystagmus can help with differentiating between central and peripheral causes.

While physician confidence with the HINTS exam (Head Impulse test, Nystagmus, and Test of Skew) is relatively low, Dr. Siket said the tool is useful for some patients. He added that provocative testing should be used selectively to be sure that it is being applied to the right patient cohort.

Dr. Siket warned that physicians shouldn’t assume a cause of benign paroxysmal positional vertigo (BPPV) because a patient’s symptoms worsen with head movement. He also cautioned that incomplete neurologic exams can lead to misdiagnoses. Lastly, he noted that misunderstanding HINTs and the types of nystagmus can cause further diagnostic confusion.

Overall, Dr. Siket said using a systematic approach to help diagnose the cause of dizziness will make physicians more comfortable dealing with dizzy patients.

“I was able to change the way I approached dizziness. It makes me much more comfortable and confident,” Dr. Siket said, adding that he’s now “admittedly less guilty of just leaving that chart in the rack and playing chicken with the other providers to see if they jump at it first.”

 Richard Quinn is a freelance writer from New Jersey.

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Phone Apps You Should Know About https://www.acepnow.com/article/phone-apps-you-should-know-about/ https://www.acepnow.com/article/phone-apps-you-should-know-about/#respond Tue, 29 Oct 2019 19:35:15 +0000 https://www.acepnow.com/?post_type=article&p=22313 Nikita Joshi, MD, FACEP, loves crowdsourcing. Whether it’s Facebook or open-access medical wikis, the director of the...

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Nikita Joshi, MD, FACEP, loves crowdsourcing. Whether it’s Facebook or open-access medical wikis, the director of the emergency department at Alameda Hospital in Alameda, California, sees the value of other people’s knowledge and opinions.

Hence her ACEP19 presentation, “There’s an App for That! Phone Apps You Should Know About,” that served both as a list of useful mobile applications – for practical use and as medical references – and as a roadmap for how and when to use them.

Dr. Joshi said that when emergency physicians are using apps as a tool, they need to let everyone in the room know that.

“You could take your phone out when you’re taking care of the patient,” she said. “Do they think you’re distracted? Do they think you’re texting your spouse? Do they think you’re ordering food? Or do they realize you’re using the app to help you take care of them?”

And it’s not just the public who needs that assurance. Dr. Joshi urged emergency physicians to realize what it looks like to colleagues when they’re checking their phone in front of a patient.

“Does it make you look more or less professional with your nurses and your team when you pull out your phone?” she asked.

Dr. Joshi noted some of the most valuable smartphone apps are built in. Take the timers, which are useful for manually counting a patient’s heart rate. Or the flashlight, which is “guaranteed going to be better than the otoscope that probably doesn’t work and is hanging on your wall.”

Among the apps that Dr. Joshi promoted for clinical practice and medical reference were Pedi STAT (for treating pediatric patients in ED/critical-care settings); Epocrates (a pharmaceutical reference tool that can identify pill by shape, color and imprint code); Eye Chart (a visual acuity tool) and palmEM (an emergency medicine reference guide).

She also highlighted Read by QxMD, an app that can serve as a single point-of-contact for burgeoning research.

“They do a great job of going through journals,” Dr. Joshi added. “If you go through their filters and tell them the specialties you’re interested in…they will email you references that have come out in recent publications.”

Another useful app – albeit it a non-medical one – is Google Translate, which is surprisingly efficient at bridging language gaps, particularly when physicians don’t want to waste time waiting for an interpreter to arrive.

“Nobody wants to have to wait an hour before we speak to an elderly, demented patient in another language,” Dr. Joshi said. “In those cases, we often end up doing more testing, more CT scans – maybe none of that is necessary.”

Dr. Joshi also suggested using apps that focus on physician well-being. Keep a DoorDash-type app on your phone to make sure that dinner doesn’t depend on the cafeteria being open. Put Peloton on there to help motivate better fitness.

But while Dr. Joshi is clearly a promoter of apps and their efficacy, her wellness concerns also tell her that sometimes it’s time to go old school.

“When it comes to our heath and the amount of screen time that we’re spending,” she said, “we may want to put down the phone, rest our eyes and actually focus on the real world.”

Richard Quinn is a freelance writer from New Jersey.

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Council Considers Social, Clinical Issues in Variety of Resolutions https://www.acepnow.com/article/council-considers-social-clinical-issues-in-variety-of-resolutions/ https://www.acepnow.com/article/council-considers-social-clinical-issues-in-variety-of-resolutions/#respond Tue, 29 Oct 2019 18:18:51 +0000 https://www.acepnow.com/?post_type=article&p=22310 The 2019 ACEP Council considered several resolutions during its annual meeting this week, including proposals related to...

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The 2019 ACEP Council considered several resolutions during its annual meeting this week, including proposals related to social issues, clinical issues, and emergency medicine practice trends.

This year’s 433-member Council represents all 53 chapters, 39 sections of membership, the Association of Academic Chairs of Emergency Medicine (AACEM), the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine.

The resolutions adopted by the Council are not official policy until approved by the ACEP Board of Directors. The Board will discuss the resolutions at their meeting on Wednesday.

The Council adopted resolutions related to:

  • Membership Verification for EM Organizations Seeking Representation in the Council­– College Manual Amendment
  • ACEP Composition Annual Report
  • Eliminating Use of the Word “Provider” in All ACEP Communications
  • Implicit Bias Awareness and Training
  • Pay Transparency
  • Promoting Emergency Medicine Physicians
  • Support of the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM)
  • Supporting Physicians to Seek Care for Mental Health and Substance Use Disorders
  • Video Conferencing for Chapter Meetings
  • Expanding Emergency Physician Utilization and Ability to Prescribe Buprenorphine
  • Establish a Rural Emergency Care Advisory Board (substitute resolution)
  • Mental Health Care for Vulnerable Populations
  • Prevention of Self-Harm & Accidental Injury by Internet Challenges and Social Media Posts
  • Stimulating Telemedicine Researchers and Programs
  • EMTALA Professional Liability Coverage
  • Extending Medicaid Coverage to 12-Months Postpartum
  • High Threat Emergency Casualty Care
  • Legal Penalties for the Routine Practice of Medicine
  • Opposing Naloxone Addition to the Prescription Drug Monitoring Program
  • Prudent Layperson Visit Downcoding
  • Research Funding and Legislation to Address Both Firearm Violence and Intimate Partner Violence
  • Standards for Insurance Denials
  • Work Requirements for Medicaid Beneficiaries
  • Telehealth Emergency Physician Inclusion
  • Supporting Vaccination for Preventable Diseases
  • Promotion of Maternal and Infant Health
  • Protecting Emergency Physician Compensation During Contract Transitions
  • Social Work in the Emergency Department
  • Medical Neutrality
  • Droperidol is Safe to Use in the ED
  • Role of Private Equity in Emergency Medicine
  • Opposition to the Sale and Commoditization of Graduate Medical Education Slots
  • Vaccinations

The Council referred these resolutions to the Board of Directors for further discussion:

  • Advancing Quality Care in Rural Emergency Medicine
  • Independent ED Staffing by Non-Physician Providers
  • International Member Eligibility for FACEP – Bylaws Amendment
  • Visual White Coat for Emergency Medicine Advocacy Efforts (in part)
  • CMS Sepsis Core Measure and the Legal Standard of Care
  • Augmented Intelligence in Emergency Medicine

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Pediatric Pearls Highlight Annual Literature Review https://www.acepnow.com/article/pediatric-pearls-highlight-annual-literature-review/ https://www.acepnow.com/article/pediatric-pearls-highlight-annual-literature-review/#respond Mon, 28 Oct 2019 22:38:03 +0000 https://www.acepnow.com/?post_type=article&p=22306 To kick off his review of published pediatric papers at ACEP19, Richard Cantor, MD, FAAP, FACEP, acknowledged...

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To kick off his review of published pediatric papers at ACEP19, Richard Cantor, MD, FAAP, FACEP, acknowledged that some parents think pediatric emergency physicians are “stupid.”

“How do you beat this moniker, this label?” asked Dr. Cantor, professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Regional Poison Control Center at Upstate Medical University in Syracuse, New York. “Beat it by knowledge, by being the smartest person in the room. More importantly, taking your knowledge and applying it to the patient.”

Dr. Cantor’s well-attended annual session, “Cruising the Literature: Pediatric Emergency Medicine 2019,” aimed to arm its audience with the latest knowledge on a cross-section of pediatric pedagogy. He weaved between infectious issues, closed-head injuries and respiratory problems.

Some of the literature was aimed at showing emergency physicians where procedure and practice diverge.  Take “Pediatric Anaphylaxis in the Emergency Department” (Pediatr Emer Care 2019;35:28-31), which reported that after reviewing 250 charts, 84 percent met the National Institute of Allergy and Infections Diseases (NIAID) clinical criteria for diagnosing anaphylaxis. Yet the study found only 68 percent of patients received epinephrine in the emergency department, or within three hours of a visit, Dr. Cantor said.

“There’s a gap between what is best practice and what we’re doing,” he added.

Other studies were presented to help assuage emergency physicians that their practices are right, even if they’ve not done clinical research. That included “Effect of an Asthma Guideline in 2 Pediatric Emergency Departments and an Urgent Care Center” (Pediatr Emer Care 2018;34:729-735).

One of the report’s conclusions was that the implementation of a clinical practice guideline (CPG) increased ordering of albuterol via metered-dose inhaler with spacer (MDI-spacer). But Dr. Cantor’s takeaway was more folksy: Albuterol. Early and often.

“Albuterol can never be used enough,” he said. “If it was up to me in Syracuse, it would be in everyone’s heating system in their home.”

Beth Cadigan, MD, FACEP, an emergency physician at Albany Medical Center in Albany, NY, said the annual session is always a valuable compendium of a year’s worth of research she doesn’t always have the time to go through, particularly as she’s not a pediatric specialist.

“It gives you a summation of the year to make sure you hear everything,” she said. “To make sure I didn’t miss something in my reading that should adjust my own practice.”

For Keith Jensen, MD, FAAP, a Houston-based regional medical director of pediatric emergency medicine, the annual literature review serves as both a chance to hear new clinical pearls – and affirm his current practices remain best practices.

“There’s some confirmation, and that’s always nice, because you know that you’re doing the right things,” Dr. Jensen said. “But there are also some little things you can pick up … sometimes it’s even nice just to know what the conversations are that are being had, so that you can keep an eye out for literature on those topics.”

Richard Quinn is a freelance writer in New Jersey.

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ACEP Introduces Citizen First Responder Training Program https://www.acepnow.com/article/acep-introduces-citizen-first-responder-training-program/ https://www.acepnow.com/article/acep-introduces-citizen-first-responder-training-program/#respond Mon, 28 Oct 2019 22:28:21 +0000 https://www.acepnow.com/?post_type=article&p=22304 ACEP’s new first responder training program, Until Help Arrives, was officially unveiled during ACEP19 in Denver with...

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ACEP’s new first responder training program, Until Help Arrives, was officially unveiled during ACEP19 in Denver with a series of events to highlight how emergency physicians can positively impact their communities by conducting training sessions to teach the public basic life-saving skills.

THE NEED
On Monday, ACEP hosted a tele-press conference to release the results of its national poll assessing the emergency preparedness of the average civilian.

The poll results were compelling, indicating that most citizens feel unprepared to step in to assist after a medical emergency. The respondents said the main reason they don’t step in to help is because they are afraid to do more harm than good.

According to poll results, confidence wanes as the emergency gets more severe:

  • 68 percent are not confident to help in the event of a mass shooting.
  • 62 percent are not confident to help if someone’s been shot.
  • 52 percent are not confident to help if someone has stopped breathing.
  • 50 percent are not confident to help if someone is severely bleeding.
  • 48 percent are not confident to help in case of a natural disaster.
  • 47 percent are not confident to help if someone has been in a car accident.

The Until Help Arrives course teaches participants how to assess scene safety, communicate with 911, control severe bleeding with or without a tourniquet and to perform compression-only CPR. The poll results indicated this type of training is sorely needed:

  • 61 percent are unprepared to administer an AED.
  • 51 percent are unprepared to control severe bleeding.
  • 42 percent are unprepared to move an endangered victim to safety.
  • 45 percent are unprepared to apply a tourniquet.
  • 41 percent are unprepared to perform compression-only CPR.

ACEP Past President Paul Kivela, MD, MBA, FACEP, who was instrumental in the creation of the program, said the poll results were surprising to him, especially since some states require CPR training for many public roles. “I was pretty shocked at how few people really feel secure delivering that type of first care.”

THE COURSE
On Friday, Oct. 25 in advance of ACEP19, emergency physicians Kristen Nordenholz, MD, FACEP, and Whitney Barrett, MD, led an Until Help Arrives training course for 20 Visit Denver and CenterPlate catering staffers, part of the city’s convention and visitor’s bureau team. Using the instructor packs provided by Until Help Arrives partner Simulab, Dr. Nordenholz and Dr. Barrett spent 20 minutes presenting the curriculum and 40 minutes leading the group in hands-on practice for bleeding control and resuscitation.

Dr. Nordenholz, associate professor of emergency medicine and the University of Colorado School of Medicine, is passionate about bringing this training to the public because she’s seen the difference firsthand that immediate CPR can make on patients who are brought to the emergency department. Plus, she felt energized because she was able to see the course making a positive impact as the students gained confidence during the class.

“People walked in quite nervous about what they were going to learn, and they walked out of the room really feeling good that they had invested 60 minutes learning how to stop bleeding and how to start compression-only CPR,” Dr. Nordenholz said.

Dr. Nordenholz is one of the first course instructors to implement Until Help Arrives in her community. Rhode Island emergency medicine residents Landon Wood, DO, and Tim Bikman, DO, have conducted several courses in their community the past few months as part of an ACEP Chapter Grant. Look for a firsthand account of their experience in the November issue of ACEP Now.

THE PROGRAM
Developed by emergency physicians, Until Help Arrives is a condensed version of FEMA’s “You’re the Help Until Help Arrives” campaign. Wondering how Until Help Arrives is different from Stop the Bleed?

One key difference is the length of the course. Until Help Arrives is the shortest course on the market, providing training in the most basic life-saving skills in a quick, one-hour format. Dr. Kivela said one of the main challenges with other training courses is that many require a half-day or full-day time commitment.

“As emergency physicians, we like doing things better, faster and less expensive, and [Until Help Arrives] is the solution.” Dr. Kivela said. “It’s really only an hour to save a life, and it’s probably one of the best hours you can invest.”

As far as curriculum differences, Until Help Arrives goes beyond bleeding control to also teach compression-only CPR. The presentation also provides instruction related to assessing scene safety, communicating with 911 and utilizing AEDs when available. The course curriculum and materials are also offered in Spanish and ACEP hopes to include more languages as the program grows. Learn more at UntilHelpArrives.com.

THE NEXT STEP
Interested in leading a course in your community? If you’re at ACEP19, head to Booth #125 to view the instructor packs and learn more about becoming an instructor. You can also fill out the instructor interest form to gain access to course curriculum and other instructor resources.

Jordan Grantham is a communications manager at ACEP.

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Posterior Strokes: “A wolf in sheep’s clothing” https://www.acepnow.com/article/posterior-strokes-a-wolf-in-sheeps-clothing/ https://www.acepnow.com/article/posterior-strokes-a-wolf-in-sheeps-clothing/#comments Mon, 28 Oct 2019 17:19:52 +0000 https://www.acepnow.com/?post_type=article&p=22302 For emergency physician Rachel Garvin, MD, FNCS, properly diagnosing posterior circulation strokes is a passion. But practicing...

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For emergency physician Rachel Garvin, MD, FNCS, properly diagnosing posterior circulation strokes is a passion. But practicing said passion can be like ferreting out a “wolf in sheep’s clothing.”

“It is something that is trying masquerade as something not really that bad,” Dr. Garvin said during her ACEP19 presentation, “Posterior Strokes: A Dizzying Differential.”  “That’s what posterior circulation strokes are. People come in (with symptoms that) don’t really seem that concerning but can be absolutely devastating … our job today is to expose this wolf. For you guys in the emergency department to be able to sniff out these patients that are presenting with posterior circulation stroke, so that you’re not missing them.”

Dr. Garvin, an associate professor in the Department of Neurosurgery at UT Health San Antonio, said posterior circulation strokes should make up roughly 20% of all ischemic strokes. But one recent review she participated in found they made up only 12.5%.

“These are being missed,” Dr. Garvin said.

Dr. Garvin said perhaps the best clinical pearl she can share to help emergency physicians diagnose posterior circulation stroke is to get their patient out of bed. Especially if they present with a seemingly benign compliant of dizziness.

“Get them up and walk them,” Dr. Garvin said. “I promise you it does not take a lot of extra time … I know we think we’re making our patients feel bad, feel worse or (say), ‘I’m so sick, I can’t get up.’

“You know what I tell people? ‘You need to get up. Here is an emesis basin, we’ll hold that for you, but we have to see how you can walk.’You will get so much information just from getting your patients up off the stretcher.”

Another practical tip Dr. Garvin suggested was trying to use cranial nerve deficits as a marker to differentiate anterior circulation stroke from posterior circulation stroke.

“The trickiest thing, but the thing that you can really catch, is cranial nerve deficits,” she said. “You will not see cranial nerve deficits in anterior circulation strokes, but you can see them in posterior circulation strokes – and you need to look for them because cranial nerve deficits can be very subtle.”

Sometimes, emergency physicians are tempted to rely on MRIs and other imaging technology to help with their diagnosis. Dr. Garvin noted that those are ancillary methods, not primary ones – such as taking a patient’s history or performing a physical exam.

“Lay your hands on the patients,” she added. “We have gotten very reliant on imaging to tell us what’s going. I will tell you that imaging will not always tell you the story.

“There is a reason why we learn to get a history and physical exam. And this is what I teach to my residents: 99% of the time, a history and physical exam can build your differential diagnosis. You are going to know what’s going on with your patient. All the tests are going to tell you is yay or nay from your differential diagnosis.”

Richard Quinn is a freelance writer from New Jersey.

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Celebrating ACEP’s 100% Club https://www.acepnow.com/article/celebrating-aceps-100-club/ https://www.acepnow.com/article/celebrating-aceps-100-club/#respond Mon, 28 Oct 2019 15:55:25 +0000 https://www.acepnow.com/?post_type=article&p=22300 ACEP’s Group Recognition Program is a great way to show your employees that you care about their...

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ACEP’s Group Recognition Program is a great way to show your employees that you care about their continued success. This year, there are nearly 140 groups in ACEP’s 100% Club. If your group is interested in participating in ACEP’s Group Recognition Program, please visit the membership area in ACEP19 registration.

Thank you to all these groups that have all eligible emergency physicians enrolled as members:

Albany Medical Center Emergency Physicians

All Childrens Emergency Center Physicians

Alvarado Emergency Medical Associates

Asheboro Emergency Physicians PA

Associated Emergency Physicians, Inc

Athens-Clarke Emergency Specialist

Augusta University

Beach Emergency Medical Associates

BlueWater Emergency Partners

Carson Tahoe Emergency Physicians, LLP

Cascade Emergency Associates

Cascade Emergency Physicians Incorporated

Catawba Valley Emergency Physicians- Wake Forest

Centinela Freeman Emergency Medical Associates

Central Coast Emergency Physicians

Centre Emergency Medical Associates

Certified Emergency Medical Specialists, PC

Charleston Area Medical Center Faculty Emergency Physicians

Chino Emergency Medical Associates

Coast Plaza Emergency Physicians

Corona Regional Emergency Medical Associates, Inc.

Covenant Health Care

District Medical Group

Doctors Emergency Services Delaware

Eastside Emergency Physicians

Elkhart Emergency Physicians, Inc

Emergency Associates of Yakima

Emergency Care Specialists WMI

Emergency Medical Associates of Tampa Bay

Emergency Medical Associates SW Washington Medical Center

Emergency Medical Specialists, PC

Emergency Medicine of Idaho

Emergency Medicine Professionals, PA

Emergency Medicine Specialists of Orange County

Emergency Physicians & Consultants, PA

Emergency Physicians of Central Florida LLP

Emergency Physicians of Indianapolis

Emergency Physicians of Tidewater

Emergency Professional Services PC

Emergency Service Associates

Emerson  Emergency Physicians LLC

Emory University- Grady Faculty

EPIC, LLC

EPPA Health Emergency Physicians

First Contact Medical Specialist

Flagstaff Emergency Physicians

Florida Emergency Physicians

Florida Regional Emergency Associates

Georgia Emergency Medicine Specialists

Georgia Emergency Physician Specialists LLC

Glendale Adventist Emergency Physicians

Grand River Emergency Medical PLC

Green Country Emergency Physicians

Hawaii Emergency Physicians Associated, Inc

HealthFront Emergency Physicians

Henry Ford Hospital Emergency Department

Hollywood Presbyterian Emergency Medical Associates

Huguley Emergency Physicians LLP

Huntington Park Emergency Medical Associates

Indiana University Health Physicians

Johns Hopkins Medical Institute Faculty

Lehigh Valley Health Network

Lehigh Valley Health Network Fellows

Los Alamos Emergency Medical Associates

Maimonides Medical Center Fellows

Maine Medical Center Emergency Physicians

Manu Memorial Emergency Medical Associates

Medical Center for Emergency Services

Medical Services of Prescott Ltd

Merrimack Valley Emergency Associates, Inc.

Mid Atlantic Emergency Medical Associates

Midland Emergency Room Corporation, PC

Montclair Emergency Medical Associates

Napa Valley Emergency Medical Group

Newport Emergency Medical Group Inc

North Sound Emergency Medicine

Northeast Emergency Medicine Specialists, LLC

Northern Nevada Emergency Physicians

Northwell LIJ Hospital Forest Hills Emergency Physicians

Orange County Emergency Medical Associates

Orion Emergency Services Inc

OUHSC Pediatric Emergency Medicine Faculty

OUHSC Pediatric Emergency Medicine Fellowship Program

Pacific Coast Emergency Medical Associates

Pacific Emergency Providers APC

Pacifica Emergency Medical Associates

Phoenix Physician Services, Incorporated

Preston MD & McMillin MD PC

Professional Emergency Physicians

Puget Sound Physicians

Pullman Regional Hospital Clinic Network, LLC

Raleigh Emergency Medicine Associates

Rapid City Emergency Services PA

Redondo Emergency Physicians

Reno Emergency Physicians

Rutgers Robert Wood Johnson Medical School Physicians

Saint Louis University Physicians

San Dimas Emergency Medical Associates

Sandhills Emergency Physicians, PA

Scottsdale Emergency Associates

Seattle Emergency Physicians Services Inc PS

Shasta Regional Emergency Medical Associates

Sherman Oaks Emergency Medical Associates

South Jersey Health System Emergency Physician Services

Southwest Florida Emergency Physicians

St Joseph Hospital Bangor Maine

St Jude Emergency Medical Group Incorporated

St Paul Emergency Room Docs, PA

Sturdy Memorial Emergency Physicians

SUNY at Buffalo Department of Emergency Medicine

Tacoma Emergency Care Physicians

Tarzana Emergency Medical Associates

Team Health Emergency Medical Specialists, MI

Temecula Valley Emergency Physicians

Tufts Medical Center EP, LLC

UAB School of Medicine Department of Emergency Medicine Faculty

UF Department of Emergency Medicine Fellow Group

UF Department of Emergency Medicine Group

UMass Memorial Emergency Medicine

University Health Associates

University of Florida Health Emergency Medicine Jacksonville

University of Kansas Physicians Department of Emergency Medicine

University of Louisville Physicians

University of Mississippi Medical Center Emergency Medicine

University of North Carolina Emergency Physicians

University of South Alabama Physicians

University of Virginia Department of Emergency Medicine

University Puerto Rico

Valley Presbyterian Emergency Medical Associates

Vituity Emergency Medicine Advocacy Physicians

Vituity Idaho-LLP

Wake Emergency Physicians PA

Washington University – Missouri

WellStar Kennestone Regional Medical Center Faculty

Wenatchee Emergency Physicians PC

West Hills Emergency Medical Associates

Westfield Emergency Physicians

White Plains Hospital Emergency Physicians

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