Articles of the month (July 2016)

Another month and another edition of the articles of the month. However, this time I have some very exciting news. I have teamed up with Casey Parker (the brilliant, smooth-talking Australian physician, not the adult film star) to produce an audio version of these summaries. You will be able to find this podcast on, a great FOAM website that everyone should probably be following anyway. This is the first edition, and we will likely tweak the format with time, so if you have any feedback (hopefully more constructive than, “Justin, you have the perfect voice for silent films”), we would love for you to get in touch.

The podcast is here:

Who needs a doctor? Just light ‘em up

Sierink JC, Treskes K, Edwards MJ. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet (London, England). 2016. PMID: 27371185

We aren’t a trauma center, so the concept of a ‘pan scan’ isn’t part of our daily vernacular. That being said, every ED sees trauma, and sometimes we do end up CTing patients that don’t obviously need trauma center activation. This is a non-blinded, multi-center RCT looking at 1403 adult patients with potentially severe injuries comparing immediate whole body CT (pan-scan) to selective CT scanning. Selective scans were decided on based on protocols. For the primary outcome of mortality, there was no difference between the two groups 15.9% vs 15.7%, p=0.92. As a secondary outcome, it should not be surprising that radiation was increased in the pan-scan group (although maybe not clinically significantly.) Really, the selective CT group still wasn’t very selective (46% of this group still got a whole body CT). There is an interesting artifact in the data. The pan-scan group looks sicker when you look at the ISS scores. However, as Rory Spiegel has pointed out, when you do a whole body CT you do end up finding more injuries, but often those injuries aren’t clinically important. However, every injury you find will increase the ISS score. So the elevated ISS probably doesn’t represent unbalanced groups. It is an artifact of increased scanning.

Bottom line: Routine, thoughtless testing is never the answer. Not for trauma. Not for anything.

Read more: EMNerd, (and even more on EMNerd), The Bottom Line, EM Lit of Note, St Emlyn’s

The ongoing saga of ondansetron for nausea and vomiting in pregnancy

Fejzo MS, MacGibbon KW, Mullin PM. Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States. Reproductive toxicology (Elmsford, N.Y.). 62:87-91. 2016. PMID: 27151373

There seems to be a lot of conflicting data on this topic. I think the most honest answer at this point is simply “we don’t know”.  This is a retrospective cohort comparing 1070 pregnancies exposed to ondansetron with 2 groups who were not exposed (women with and without hyperemesis gravidarum). There was no difference in teratogenicity. Overall, the rate was 3.4% in the ondansetron group and 3.4% in the ondansetron negative group (p=1.0). With regards to ventricular septal defects in particular, the recent concern, there were 2/952 with ondansetron and 4/1286 with no ondansetron (no difference). However, the ondansetron group had less miscarriages, fewer terminations, and higher rates of live births. These are very important considerations in the overall balance of harm to benefit that are often overlooked.

Bottom line: We can’t know for sure. Ondansetron may increase birth defects, although if it does, the rates will likely be low. However, we don’t know if any of the other options are actually safer.  

Maybe ondansetron is worse for your heart after you are born? (Or not)

Krammes SK, Jacobs T, Clark JM, Lutes RE. Effect of Intravenous Ondansetron on the QT Interval of Patients’ Electrocardiograms. Pediatric emergency care. 2016. PMID: 27261956

Another quick one on ondansetron. We have heard for a while that ondansetron is probably not much different from droperidol in terms of the dreaded QT prolongation that earned droperidol its black box. This an observational study looking at 100 pediatric patients (aged 6 months to 18 years) receiving ondansetron for vomiting in the emergency department. They measured QTs at baseline, at ondansetron’s peak effect (3 minutes when given IV), and 1 hour later. There was no statistically significant change in the QT interval. There also wasn’t a clinically significant increase in QT interval (mean increase of 3 milliseconds at 3 minutes). Of course, we already knew this, as we give millions of doses of this medication safely every year. However, a study this small can’t really prove safety, or rule out significant QT prolongation in a small number of patients.

Bottom line: All medications have side-effects. We should only prescribe them when they are needed. But come one – ondansetron is clearly safe and effective.

Platelets to reverse antiplatelets?

Baharoglu MI, Cordonnier C, Al-Shahi Salman R. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet (London, England). 387(10038):2605-13. 2016. PMID 27178479

This is an open-label, multicenter RCT comparing platelet transfusion to no transfusion in adult patients with acute intracranial hemorrhage who had been on antiplatelet therapy in the prior 7 days. They enrolled 190 patients. The primary outcome, death or disability on a modified Rankin score using an ordinal analysis, was worse in the transfusion group (adjusted OR 2.05; 95% CI 1.18 – 3.56; p = 0.01). 3 month mortality was also worse in the transfusion group (68% vs 77%), although the difference was not statistically significant. There were a few problems with this trial, including its small size, lack of blinding, and baseline differences between the two groups, but it is the best trial we have on this topic to date.

Bottom line: Platelets don’t seem to help in patients with intracranial hemorrhage who have been taking antiplatelet medications – although this trial is not strong enough to definitely settle the issue.

Read more: REBEL EM, EM lit of note

The pain-free ED – minimizing children’s pain

Ali S, McGrath T, Drendel AL. An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond. Pediatric emergency care. 32(1):36-42; quiz 43-4. 2016. PMID: 26720064

This is a nice quick review that goes over the evidence behind the things we can do to limit procedural pain in kids (although, really, we should be applying these concepts to adult patients as well). Sucrose is there, although I still think that real pain medication is better than placebo (sugar) for children. We should use topical anesthetics for needles and IVs. They talk about various distraction techniques, such as music, toys, or watching cartoons. Parental presence helps kids as does allowing them to breastfeed during the procedure. For lacerations, we should be buffering our lidocaine with bicarb, and when possible using skin adhesives. One thing I didn’t know and might change practice for people is that venipuncture is significantly less painful than heel lance. The only thing that wasn’t mentioned, but I think is an essential tool, is intranasal analgesia and sedation.

Bottom line: These are all techniques that we should be applying routinely

Epinephrine in digital blocks – the benefits

Welch JL, Cooper DD. Should I Use Lidocaine With Epinephrine in Digital Nerve Blocks? Annals of emergency medicine. 2016. PMID: 27125816

I’ve discussed papers that indicated epinephrine is safe in digital blocks before, but that always raised the question of why you would want to use epinephrine. This is a systematic review looking at RCTs comparing lidocaine plus epinephrine to lidocaine alone in digital nerve blocks. One study looked at duration of anesthesia: it was a median of 3.2 hours longer in the epinephrine group (95%CI 2.5-3.9). 2 studies looked at bleeding: it was also less in the epinephrine group (RR 0.35, 95%CI .02-0.7). There were no adverse events. Of course, these are small studies, but we know epinephrine has these advantages when used elsewhere in the body, so why not in the digits?

Bottom line: Not only is epinephrine safe in digital blocks, but there may be some advantage to using it as well.

The elbow fat pad: could this really be another example of dogma?

Jie KE, van Dam LF, Hammacher ER. Isolated fat pad sign in acute elbow injury: is it clinically relevant? European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 23(3):228-31. 2016. PMID: 26153882

Orthopedics is one area of emergency medicine that seems to be rife with dogma. I was taught to cast buckle fractures and Salter-Harris 1 injuries, but no longer do either. I was told I should never use NSAIDs in patients with fractures, but think that is probably a myth. However, for some reason, it had never occurred to me that this could be a myth: the fat pad sign in the elbow is a clear indication of a fracture, or serious injury. This is a subset of a prospective observational trial, in which 587 adults with acute isolated elbow injuries all had x-rays done. This study looked at the 111 (19%) that had an isolated fat pad (anterior sail sign and/or posterior fat pad) but no other injuries seen on the x-ray. The standard practice for these patients was an elastic bandage and a sling, with orthopedics follow-up in 1 week. (Where I work, children generally get a plaster splint, as we are concerned about occult supracondylar fractures.) At the 1 week follow up, there were no significant injuries identified, although they did not routinely get follow-up x-rays. Only 1 patients was transitioned to a cast because of ongoing pain. Unfortunately, they did lose 17% of the patients to follow-up at 1 week. They had long term follow up (phone calls 22 months later) on 90% of the patients, and there were no patients with persistent symptoms that prevented them from carrying out their daily activities.

Bottom line: The classic teaching that an elbow fat pad signs indicates an occult fracture could be wrong

Another pediatric ortho myth?

Schuh AM, Whitlock KB, Klein EJ. Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatric emergency care. 32(7):452-4. 2016. PMID: 26087443

This is another paper about a potential pediatric orthopedics myth – although without much in the way of evidence. Perhaps the most interesting part of the paper is the reference to prior orthopedics literature that argues that toddler’s fractures almost never displace, so there may not be any real reason to immobilize these children for prolonged lengths of time. The study  is a retrospective chart review, looking at all the children aged 9 months to 3 years diagnosed with a toddler’s fracture (undisplaced spiral fracture of the tibia) based on x-ray at their single tertiary pediatric emergency department. Interestingly, 9% of children with spiral fractures on x-ray were managed without any immobilization at this center. 24% were given a removable boot, and the remaining 67% were splinted or casted. Unfortunately, we don’t have any information on pain control, short term, or long term functionality, so we really can’t conclude anything except that there are pediatric specialists out there managing toddler’s fractures without immobilization. Somewhat concerningly, 17% of their cohort ended up with skin breakdown from their cast or splint, so there is probably a legitimate question about whether the benefits of immobilization outweigh harms in a condition where displacement is essentially unheard of..

Bottom line: Not nearly enough to change practice, but certainly thought provoking

I am unsure exactly what to do with this paper

Wray CM, Loo LK. The Diagnosis, Prognosis, and Treatment of Medical Uncertainty. Journal of graduate medical education. 7(4):523-7. 2015. PMID: 26692960

This is an nice editorial reviewing uncertainty in medicine that is worth reading. They point out that no matter how much information we are able to gather, the inherent complexity of human life, the variability of presentations, and the fact that we cannot predict the future will always leave us with an intrinsic uncertainty. They point out the problem in medical education in that we value certainty from our students, and present them with black and white multiple choice exams that don’t well represent the grey of real life medicine. They close with an excellent quote from Sir William Osler: “A distressing feature in the life of which you are about to enter … is the uncertainty which pertains not alone to our science and art, but the very hopes and fears which make us men. In seeking out the absolute truth we aim for the unattainable, and must be content with finding broken portions.’’

Bottom line: Every doctor must be comfortable and quick to admit “I don’t know”

Enough flip-flopping to make you think Cochrane is running for office

Gagyor I, Madhok VB, Daly F. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). The Cochrane database of systematic reviews. 2015. PMID: 26559436

This whole topic is a mess and I don’t think I can sort it out for you. The prior cochrane review on this topic demonstrated no benefit to the use of antiviral medications for the treatment of Bell’s palsy. This updated review adds 3 new trials and a total of 300 patients and they came to a different conclusion. However, this is a revised version of the review. The same author group published the same review earlier in 2015. At that point it included 1 more trial (of 500 patients) and their conclusions were that there was no significant benefit to adding antivirals to corticosteroids for the treatment of Bell’s palsy. That trial (Abdelghany et al 2013) has been removed, because they are questioning the reliability of the data, and now it does look like antivirals might help. For what is is worth, incomplete recovery and ‘crocodile tears’ were both better with antivirals (RR 0.61 95%CI 0.39-0.97 and RR 0.56 95%CI 0.36-0.87 respectively.) Honestly, I am not sure what to make of these results. The fact that you couldn’t see a benefit with 2000 patients in the prior Cochrane review means any benefit is likely to be small. The quality of a meta-analysis is dependent on the quality of the included studies – which leaves us with just a bunch of poor quality data here. A single large, high quality RCT would overrule all of this data. Probably the most important point for me is that these trials do not adequately report harms (with only 3/10 mentioning adverse events), so there is no way to know is the small potential benefit outweighs the harms.

Bottom line: It’s a positive Cochrane review, so I wouldn’t blame you if you used it to change your practice, but personally I think there are way too many issues with this data and will continue not suggesting antivirals in Bell’s palsy

Another knock against amiodarone

Ortiz M, Martín A, Arribas F. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal. 2016. PMID: 27354046

This is a multicenter, randomized trial comparing amiodarone (5mg/kg over 20 minutes) to procainamide (10mg/kg over 20 min) in 74 adult patients with hemodynamically stable ventricular tachycardia. The results will be surprising to anyone who has listened to drug reps or the AHA over the last 15 years, but probably not surprising to anyone who has read the prior amiodarone literature. Procainamide was better. The primary outcome of cardiac adverse events (mostly hypotension requiring cardioversion), occurred in 9% of the procainamide group and 41% of the amiodarone group (odds ratio 0.1, 95%CI 0.03-.06, p=0.006). In terms of stopping the v.tach, procainamide worked 67% of the time as compared to only 38% with amiodarone (OR = 3.3; 95% CI 1.2-9.3; P = 0.026). Unfortunately, the trial was originally designed to include 300 patients, but they stopped it early because of slow recruitment. However, this comparison may not be all that relevant to you if, like me, you prefer to go straight to electricity in these patients.

Bottom line: Amiodarone is definitely not as good as cardiologists think it is

The vital signs are better – this couldn’t be PE

Kline JA, Corredor DM, Hogg MM, Hernandez J, Jones AE. Normalization of vital signs does not reduce the probability of acute pulmonary embolism in symptomatic emergency department patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 19(1):11-7. 2012. PMID: 22251189 [free full text]

This is a good study, but I worry that the results could be misinterpreted to the detriment of our patients. This is a prospective, single center diagnostic accuracy study, looking at whether normalization of initially abnormal triage vital signs lowered the chance of pulmonary embolism in adult emergency department patients. (Any single center that Jeff Kline works at might be very different from other centers in terms of PE diagnosis, potentially limiting generalizability.) These were non-consecutive patients who were identified because the treating clinicians ordered a CTPA (the key to interpreting this data). The overall rate of positive CTs in this cohort is 5%. Change in vital signs did not predict PE and the vital signs changed the same amout in both the PE positive and negative groups. However, this was only in patients for whom the physician was concerned enough to order a CT scan. There might be a large group of patients whose vital signs normalized, and the physicians actually used that information to rule-out PE, and so never ordered the CT. If they were included, it is possible that changing vital signs would be predictive. I have never used normalizing vital signs as a way to eliminate PE, but I do worry about this data being taken too far. (And I have seen some overreaching interpretations on Twitter). A healthy young person with a heart rate of 65 at the time that I am seeing them is unlikely to have a clinically significant PE, even if when they nervously walked up to triage their heart rate was 105. A single abnormal number does not overrule your clinical judgement. People with no pretest probability of a PE should not be getting a D-dimer sent just because of a single abnormal heart rate at triage.

Bottom line: Normalizing vital signs do not rule out PE in patients who you are still concerned enough about PE to order a CT scan

Apparently babies don’t need oxygen

Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA pediatrics. 170(6):602-8. 2016. PMID: 26928704

This is one of a number of recent publications that downplay the importance of oxygen saturation in bronchiolitis. If true, this might be helpful, as even if the sats are a little low, there isn’t anything I can do to help these kids aside from admitting them to hospital for oxygen therapy, which seems like overkill in a self-limited, generally safe viral disease. However, I am not sure that any of these studies are looking at the outcomes we should care about. This is a prospective cohort from a single center (Sick Kids in Toronto) of 118 healthy infants (aged 6 weeks to 12 months) who were discharged home from the ED with acute bronchiolitis. They sent the children home attached to a continuous oxygen saturation monitor, but the display was turned off. They found that 64% of the children had at least 1 desaturation event (O2 sat less than 90% for at least 1 minute). The median length of desaturation was 3 minutes and 22 seconds (interquartile range 1:54 to 8:50). 50% of children had desaturations to 80% or lower for more than one minute, and 25% had desaturations of 70% or lower. The primary outcome of unscheduled medical visits was the same whether or not you had a desaturation, so the authors conclude that pulse oximetry is not an effective tool. However, this is clearly not the most appropriate primary outcome when talking about oxygen saturation. I worry about a low sat because you are starting to fall off the hemoglobin dissociation curve. It isn’t follow up visits that I care about, but death – but that is such a rare outcome, that a study this small has no chance of telling us is these desaturations are safe. Also, if you are desaturating for longer than 8 minutes, I am worried about your brain cells, but we are going to need some very long and intensive studies to determine if there are any changes there.

Bottom line: There is a push to lower your oxygen goals in bronchiolitis, and I am always for doing less in medicine, but none of the evidence to date is strong enough to prove safety.  

Surprisingly, a medication that doesn’t decrease pain was shown not to decrease pain

Friedman BW, Cabral L, Adewunmi V. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of emergency medicine. 67(1):32-39.e3. 2016. PMID: 26320523

Is diphenhydramine part of your cocktail for managing migraines? This is a randomized, double-blind RCT comparing metoclopramide 10mg IV, either with diphenhydramine 50mg IV or placebo in 208 adult emergency patients with migraines. There was no difference in the primary outcomes of sustained headache relief at 48 hours (40 vs 37%). There was also no difference at 1 hour. However, I think this represents a misunderstanding of why diphenhydramine is used. It is not used to treat pain, but rather to prevent the extra-pyramidal side effects of other migraine medications we use. (Although, I think it makes more sense to just wait and give it to the few patients that need it, rather than just treating everyone prophylactically.)

Bottom line: Diphenhydramine was never going to decrease pain, if anyone thought that it did

Cheesy Joke of the Month

What did the pony say when it had a sore throat?

I apologize, I am a little horse!

Articles of the month (June 2016)

A monthly summary and brief critical appraisal of the best emergency medicine literature I have encountered

Biggest non-news of the month

ATTACH-2 trial: Qureshi AI, Palesch YY, Barsan WG. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The New England journal of medicine. 2016. PMID: 27276234 [free full text]

To date, all the evidence available has indicated no clinically important benefit to lowering blood pressure in people with head bleeds. However, evidence is never enough to stop people from talking about how much an intervention “makes sense”. This is a large, randomized, multi-center, open-label trial that compared intensive blood pressure management (target systolic 110-139) to standard BP management (target 140-179) in 1000 patients with acute intracranial hemorrhage. To get into the trial, you needed at least one systolic blood pressure measurement over 180. Blood pressure was maintained in the target zone for 24 hours after enrollment. The primary outcome was 90 day death or disability, represented by a modified Rankin score of 4-6, and was the same for both groups (38.7% intensive vs 37.7% standard). There were no important differences in secondary outcomes. Despite the excitement for intensive treatment that somewhat inexplicably sprang from previous negative trials, like INTERACT-2, this negative finding is in keeping with all the evidence on this topic to date. Although both groups here were managed to some target, it’s not clear to me that any blood pressure management is really required. As long as you remember to treat their pain, the blood pressure generally normalizes anyway.

Bottom line: There is no need to aggressively manage blood pressure in patients with head bleeds.

You don’t remember INTERACT-2?

Anderson CS, Heeley E, Huang Y. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. The New England journal of medicine. 368(25):2355-65. 2013. PMID: 23713578 [free full text]

This is a multi-center, randomized, partially blinded trial comparing intensive blood pressure control (target of a systolic pressure <140 within 1 hour) to guideline recommended care (to a target systolic <180) in 2794 adult patients with intracerebral hemorrhage within the last 6 hours. It was a negative trial, with the primary outcome of death or disability (modified Rankin score 3-6) at 90 days of 52.0% in the intensive group and 55.6% in guideline group (p=0.06, OR 0.87, 95%CI 0.75-1.01). This is obviously pretty close to statistically significant, and a secondary outcome using the relatively controversial ordinal analysis was statistically significant, so a lot of people seemed to overlook the fact that it was a negative trial. Interpreted in isolation, you might think that this could be a positive result trying to escape our slavish devotion to p values, but in the larger context of the recurrent negative trials, this is just another negative trial.

Bottom line: There is no evidence out there that really supports aggressive blood pressure control in patients with head bleeds.

OK – blood pressure might not help, but surely brains need salt?

Berger-Pelleiter E, Émond M, Lauzier F, Shields JF, Turgeon AF. Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials. CJEM. 18(2):112-20. 2016. PMID: 26988719

I have heard hypertonic saline mentioned as a replacement for mannitol for the treatment of intracranial hypertension at numerous conferences since finishing residency. I was under the impression it was becoming the treatment of choice, but there is a reason we practice evidence based medicine. This is a systematic review and meta-analysis that identified 11 RCTs covering 1820 adult patients with traumatic brain injury comparing hypertonic saline to either mannitol (½ the studies) or another solution (often normal saline, or even hypotonic saline.) Hypertonic saline did not decrease mortality (RR 0.96, 95%CI 0.83-1.11). It didn’t lower intracranial pressure (weighted mean difference -0.39, 95%CI -3.78 – 2.99). And it didn’t improve functional outcomes (RR 1.12, 95% CI 0.92-1.36). Having the same outcomes as mannitol may not be bad, but in ½ these studies hypertonic saline was compared to iso or even hypotonic crystalloids (placebo?) and didn’t perform any better. On the other hand, it doesn’t look any worse than mannitol, so there still may be a role somewhere for it in trauma.

Bottom line: We probably shouldn’t be rushing to change to hypertonic saline in the management of traumatic brain injury.

EDIT: Scott Weingart has pointed out that the individual studies included in this review really weren’t designed to make the conclusions these authors make. (See the comments below). I haven’t read the individual studies yet, but once I do, I will provide an updated post on all the evidence for hypertonic saline. 

We desperately need droperidol back

Meltzer AC, Mazer-Amirshahi M. For Adults With Nausea and Vomiting in the Emergency Department, What Medications Provide Rapid Relief? Annals of emergency medicine. 2016. PMID: 27130801

This is a systematic review of RCTs looking at the treatment of nausea and vomiting in the emergency department. They found 8 trials that covered 952 patients. The ONLY medication that demonstrated a statistically significant decrease in nausea at 30 minutes was droperidol. Metoclopramide, ondansetron, prochlorperazine, and promethazine were all statistically nondifferentiable from placebo, and even if you had larger numbers, the magnitude of change with those drugs is likely clinically insignificant (about 0.5/10 on a VAS). Droperidol decreased nausea by 1.6/10 at 30 minutes.

Bottom line: Once again, droperidol is a very valuable drug, that was taken away from us for no good reason.

Single dose dex for asthma – again

Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma. Annals of emergency medicine. 2016. PMID: 27117874

Have I beat this one to death yet? A steroid is a steroid is a steroid. However, the previous papers I have covered on this topic were in children – so I’ll throw this in. This is a randomized, double-blind, non-inferiority trial comparing a single dose of dexamethasone (12mg) to a 5 day course of 60mg of prednisone in 376 adult emergency patients with asthma exacerbations. The primary outcome of recidivism at 14 days was essentially the same (12.1% vs 9.8%, 95%CI -4.1 to 8.6%). However, because they defined non-inferiority as 8%, and the confidence interval is relatively wide, they cannot conclude that dexamethasone is noninferior. Personally, I think based on those numbers it probably is going to be, and that this trial was just under powered – but perhaps we should be giving a second dose of dex the next day.

Bottom line: Single dose dexamethasone is probably just as good as 5 days of prednisone in adults with asthma.

Can’t touch this (Stop. Hammer time.)

Ferguson CM, Swaroop MN, Horick N. Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology.34(7):691-8. 2016. PMID: 26644530

Physiologically speaking, I could never quite understand why I was supposed to avoid drawing blood or measuring blood pressures in the arm that a breast cancer patient had axiallry lymph node dissection on. It is supposed to be a disaster resulting in lymphedema, and patients can get very angry if you try – but what exactly was the mechanism of disaster? Well, maybe there isn’t one. This is a prospective study of postoperative breast cancer patients being screened for lymphadenopathy, comparing patients who had blood draws, blood pressure measurement, injections, trauma, and cellulitis in the affected arm to those who didn’t. They also compared number of times on an airplane. The biggest weakness in this data is that although the lymphedema data was collected prospectively, data about the exposures was based on patient report and is therefore subject to recall bias. None of venipuncture, injection, or blood pressure measurements had any association with lymphedema. For patient information, the number of flights and length of flights were also not associated with lymphedema. This data is not enough to prove safety, but given the dubious physiologic explanation, this is reassuring.

Bottom line: You are unlikely to cause lymphedema by doing simple ED procedures such as injections, blood draws, or blood pressure measurements.

Hippocrates has still got it

St John PD and Montgomery PR. Utility of Hippocrates’ prognostic aphorism to predict death in the modern era: prospective cohort study. BMJ 2014. PMID 25512328 [free full text]

Another gem from the BMJ Christmas edition. One of Hippocrates’s aphorisms was: “It augurs well, if the patient’s mind is sound, and he accepts all food that’s offered him; but, if the contrary conditions do prevail, the chances of recovery are slim”. In other words, good appetite and good cognition make survival more likely. Using data from the Manitoba Study of Health and Aging, a prospective cohort study, these authors tested that theory. Combined, poor appetite and poor cognition predicted death, with a hazard ratio of 2.37. Both components were individually predictive, with poor appetite and cognition having hazard ratios of 1.79 and 2.21 respectively. They conclude, “An aphorism devised by Hippocrates millennia ago can predict death in the modern era.”

Bottom line: Hippocrates was probably a better clinician than all of us. (Also, these are important factors to think about when discussing end of life issues with our patients.)

Reminder: we treat patients, not numbers (times three)

Nakprasert P, Musikatavorn K, Rojanasarntikul D, Narajeenron K, Puttaphaisan P, Lumlertgul S. Effect of predischarge blood pressure on follow-up outcomes in patients with severe hypertension in the ED. The American journal of emergency medicine. 34(5):834-9. 2016. PMID: 26874395

This is a single center prospective observational study looking at 146 consecutive adult emergency department patients with a blood pressure ≥ 180/110 and no acute end-organ damage (the so called “hypertensive urgency”). One exclusion criteria that could be useful to you clinically was if patients had their BP decrease to less than 180 with just 10 minutes of quiet bed rest, which happened in 16/221 (7%) of the patients screened. They compared patients who had a blood pressure less than 180 at the time of discharge (98 patients) to those who still had a pressure over 180 at discharge (48 patients). There were no differences between these two groups. In fact, only 1 patient (0.7%) had a “hypertension related adverse event”, and that was in the group with the lower blood pressure at discharge. (The adverse event was just a patient who returned with an asymptomatic 5cm descending thoracic aortic aneurysm for which no intervention was done.) This trial was nonrandomized, and almost everyone was given antihypertensives, even though we know there is no value and potential harm in asymptomatic patients. Also, it is really hard to draw conclusions from a trial with an event rate of 1. However, we already know that asymptomatic hypertension does not require ED treatment. This study tells you that there is no need to get a lower number recorded on the chart before discharge. The outcomes are the same.

Bottom line: Don’t treat asymptomatic hypertension, even if someone has used the utterly useless label “urgency”

Patel KK, Young L, Howell EH. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA internal medicine. 2016. PMID: 27294333

This is a retrospective, single-center cohort study of 59,535 patients with hypertensive “urgency” (systolic ≥180 and/or diastolic ≥110 but without symptoms) in an outpatient clinic. Apparently only 426 (0.7%) were referred into the emergency department, which either tells you this database is awful or the physicians are excellent. Major adverse cardiac events (MACE) at 30 days were 0.5% in the patients referred to the ED and 0.2% in those sent home (p=0.23). At 6 months, the numbers were 0.9% and 0.8% (p=0.83) respectively. They conclude: “referral to the ED was associated with increased use of health care resources but not better outcomes.”

Bottom line: There is no such thing as hypertensive “urgency”. Stop using the term. Stop treating the number.

(If any primary care physicians that end up reading this: asymptomatic patients DO NOT need to be sent to the emergency department because of high blood pressure, no matter what the number.)


Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Annals of emergency medicine. 2016. PMID: 27353284

This is another retrospective, single-center study looking at all patients presenting to the emergency department with a glucose above 22mmol/L (400mg/dL) and subsequently discharged. Patients with type 1 diabetes were excluded. They found 422 patients with 566 encounters for the chart review. Looking at the blood glucose level at the time of discharge, there was no difference in adverse events (primarily re-visits for hyperglycemia, without any consequence) whether you got the glucose level down during the visit or not. In fact, the mean discharge glucose level was lower in patients that had subsequent adverse events than those without (17.6mmol/L vs 18.6mmol/L). Only 2 patients had glucose related adverse events (0.4%), both DKA. Overall, the discharge glucose level was not associated with return visits, ED usages, or hospitalization.

Bottom line: We need to rule out underlying pathology in hyperglycemic patients, but there is no value in temporarily lowering glucose and getting a better number on the chart. These patients just need close follow-up.

How about a shot in the arm?

Kashani P, Asayesh Zarchi F, Hatamabadi HR, Afshar A, Amiri M. Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation. Turkish Journal of Emergency Medicine. 16(2):60-64. 2016. [free full text]

This is a randomized, controlled trial of 104 emergency department patients with anterior shoulder dislocations comparing intra-articular lidocaine (20ml of 1% lidocaine, landmark based) to intravenous procedural sedation for reduction. (The biggest weakness of the study is that they used midazolam (0.05mg/kg) and fentanyl (1mcg/kg) as their sedation agents, which most people don’t use any more, and have been shown to have a higher complication rate. The reductions were attempted 15 minutes after the shoulder injection. Pain scores were less during the reduction in the intra-articular lidocaine group (0.3/10 versus 3/10, p<0.001). Pain scores were the same post-reduction (1/10 in both groups). However, there were 9 patients in the injection group who were “completely dissatisfied” with their care, as compared to 0 in the sedation group. Adverse events were higher in the sedation group: there were 0 adverse events with the injections, versus 11% apnea and 10% hypoxia with the sedation. Those numbers are really high, and good reasons not to use the fentanyl/midaz combo. I have used intra-articular lidocaine a number of times, primarily ultrasound guided, and I like it – but I would still personally rather be sedated if my shoulder was out. I had been using this for post-reduction pain, but that was unchanged in this study.

Bottom line: Intra-articular lidocaine can definitely be used to reduce shoulder dislocations, but its exact role as compared to sedation still isn’t clear

Read more here:

LEMONS is a lemon?

Norskov AK, et al. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia 2014. PMID: 25511370 [free full text]

We all know how to assess patients to predict a difficult airway – the classic LEMONS assessment – but are those assessments any good? This is a database study, looking at a cohort of 188,064 Danish anesthesia cases. There were 3391 difficult intubations, and 3154 (93%) were unanticipated. In 929 cases the anesthesiologists predicted difficult intubation, and it was only actually difficult in 229 (25%). Similarly, difficult bag valve mask ventilation was unanticipated in 808/857 (94%) of cases, and predictions of difficulty were only correct in 49/218 (22%).

Bottom line: We cannot predict difficult airways. Be prepared and have a set algorithm you are going to follow for every airway, no matter how easy you think it is going to be.

Obsessive twitter users beware

Alim-Marvasti A, Bi W, Mahroo OA, Barbur JL, Plant GT. Transient Smartphone “Blindness”. The New England journal of medicine. 374(25):2502-4. 2016. PMID: 27332920

I just found this case report interesting. They present 2 patients with transient monocular blindness. They had normal workups, but both patients experienced this after looking at their smartphones while lying in bed. They think that the blindness was the result of one eye being blocked by the pillow, so that it was dark-adapted, while the other was looking at the bright screen and therefore became light-adapted. When the phone was turned off, and both eyes were used in the dark room, the light-adapted eye was perceived as being blind for a number of minutes.

Bottom line: Physiology can still be interesting

Chest compressions can’t circulate blood you don’t have

Bowles F, Rawlinson K. BET 3: The efficacy of chest compressions in paediatric traumatic arrest. Emergency medicine journal : EMJ. 33(5):368. 2016. PMID: 27099381

Cardiac arrest means push hard and push fast. That has been branded into our grey matter. However, most trauma experts I have spoken with don’t think that there is much of a role for chest compressions in traumatic cardiac arrest. They just get in the way of what you really need to be doing, if there is any chance of salvage, which is opening the chest. However, my experience in community hospitals is that this distinction between traumatic and non-traumatic arrests is not well known. This is a review looking for evidence of the benefit of chest compressions in pediatric traumatic arrests. There is no evidence, so it’s not much of a paper. They just conclude that you should follow local guidelines. I see no reason that children should be different from adults in this scenario, but there also isn’t great evidence in adults.

Bottom line: We have no idea whether we should be doing chest compressions in traumatic cardiac arrest. Just make sure that your compressions don’t result in injuries to staff trying to perform important procedures.

The authors’ title is best: Docusate: A placebo pill for soft poops

Carbon J and Kolber M. Docusate: A placebo pill for soft poops. Tools for practice. Alberta College of Family Physicians. April 25, 2016. [free full text]

This review looked at whether docusate sodium (Colace) or docusate calcium (Surfak) are effective for prevention or treatment of constipation. They identified 3 RCTs of docusate versus placebo in functional or medication induced constipation, and all were negative. One RCT compared docusate to polyethylene glycol, and the polyethylene glycol resulted in a bowel movement 1-2 days earlier. Biggest limitation: these trials were not in emergency department patients.

Bottom line: There is probably no role for docusate in the management of constipation.

I know a number of people who like to chase their drugs with a good fatty meal – and now we can give it to them intravenously

Lam SH, Majlesi N, Vilke GM. Use of Intravenous Fat Emulsion in the Emergency Department for the Critically Ill Poisoned Patient. The Journal of emergency medicine. 2016. PMID: 26972018

This is a review, but not surprisingly, considering that it is a toxicology paper, they only found 1 RCT. The majority of the ‘evidence’ is from 4 retrospective cohorts, and 79 case reports. In other words, there really is no evidence – but we still need to know what to do, so here is what they suggest. They think intralipid therapy is ‘probably’ beneficial for all local anesthetic toxicity. (I reviewed that topic here.) There is a long list of drugs that they conclude may have a ‘possible benefit’, including amitriptyline, calcium channel blockers, cocaine, and beta-blockers – based entirely off low quality case reports. They suggest it should be used if the patient is hemodynamically unstable and not responding to standard resuscitation, and that the dose is 20% intravenous fatty emulsion as a 1.5 ml/kg bolus, then an effusion of 0.25ml/kg/min for up to 60 minutes. The bolus could be repeated once at 5 minutes.

Bottom line: In the dying tox patient, this might be worth a try. I would definitely use it with local anesthetic toxicity, but otherwise would probably speak with poison control.

Cheesy joke of the month

Doctor: Sir, were you using a condom during the last time you had sex?

Patient: Doctor, what do you mean by “the last time”!?

Thanks for reading. If you find these monthly summaries useful, or you know anyone else who might find them useful, please spread the word. I love doing this, but it is really only valuable if the information reaches people who might use it. On the other hand, if you have any suggestions for improvement or come across any articles that you think should be included, please feel free to contact me.

Articles of the month (May 2016)

My monthly summary of the best reads from the emergency medicine literature

Welcome to the May 2016 edition of my favourite reads from the medical literature. This will probably be the last post on First10EM for a little while, as I plan to take a summer vacation as well as a prolonged Ireland stay for SMACC.

Gastro game changer

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 315(18):1966-74. 2016. PMID: 27131100

Kids just want to drink juice, but I’ve been told that if I let kids with gastro drink juice they will die (or something like that). This is a randomized, controlled non-inferiority trial out of the Hospital for Sick Children that compared an electrolyte solution to a combination of half strength apple juice in the ED and the child’s preferred fluid (juice or milk) at home. 647 children aged 6 to 60 months with acute (less than 96 hours) diarrhea or vomiting with mild dehydration were included. For the primary outcome, which unfortunately was a composite of a number of things including IV use, hospitalization, health care contact, and prolonged symptoms, the juice group had a ‘treatment failure’ rate of 16.7% as compared to 25.0% with the electrolyte solution (difference 8.3%; 97.5% CI 2% – infinity). Converting from a non-inferiority analysis to a superiority analysis resulted in a p value of 0.006. In other words, the juice group was statistically better than the electrolyte group. The biggest caveat is that these kids were not sick, so the results could be different in kids with even moderate dehydration.

Bottom line: I am no longer forcing kids to drink something they hate. Whatever their preferred liquid is, it will keep them hydrated.

This is another paper that will be featured on EMCases Journal Jam. If you have questions you want the author to answer, let me know.

I’m not so ENCHANTED

Anderson CS, Robinson T, Lindley RI. Low-Dose versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke. The New England journal of medicine. 2016. PMID: 27161018 [free full text]

I am honestly surprised that I managed to read an entire article that started with the statement: “Thrombolytic therapy with intravenous alteplase (recombinant tissue-type plasminogen activator) at a dose of 0.9 mg per kilogram of body weight is an effective treatment for acute ischemic stroke, despite increasing the risk of intracerebral hemorrhage.” (This is a good reminder that when reading articles, it is often best to just skip the introduction. This section is just a non-systematic review of the topic, aka a statement of the author’s biases and opinions.) Moving beyond that, this was a multi-center, prospective, randomized, open-label, non-inferiority trial comparing usual dose tPA (0.9mg/kg) to low dose tPA (0.6mg/kg) in 3310 patient with acute ischemic stroke within 4.5 hours of onset. (As a reminder of how rarely we use this intervention, they screened 69305 patients to enroll those 3310.) The primary outcome was a composite of disability and death, defined as a modified rankin score of 2 or more. There was no statistically significant difference between the two groups (53.2% low dose and 51.1% usual dose, p=0.51). However, the 95% confidence intervals around this result go beyond a pre-specified definition, therefore they were unable to demonstrate non-inferiority. For the primary harm outcome, there was less intracranial bleeding in the low dose group  (1.0% vs 2.1% (p=0.01) by SITS-MOST criteria or 5.9% vs 8.0% (p=0.02) by NINDS criteria). Death at 7 days was lower in the low dose group, but death at 90 days was unchanged. There are a number of problems with this study. I am not going to delve too deeply into the issues of comparing different doses of placebo. (A dose response relationship is generally something we look for in efficacious therapies.) There is really no reason to make a study like this open-label and unfortunately that introduces a number of potential biases. Almost all the follow up was done by phone and the modified Rankin score is notoriously unreliable. Finally, like almost all of this research, the authors have significant conflicts.

Bottom line: High dose, low dose, no dose? I like this line of research. Maybe we can just keep lowering the tPA dose until is diluted by a factor of 10300 and hand care of acute stroke patients over to the homeopaths.

Read more: Rebel EM, The Bottom Line, EM Nerd

Neuropathic analgesia?

Therapeutics Initiative. Benefits and harms of drugs for “neuropathic” pain. Therapeutics Letter. 2016; 96:1-2. [free full text]

We see a lot of chronic pain. More than a lot. Since I started practicing, the number of people on gabapentin or lyrica for their neuropathic pain has skyrocketed. But just how good are these medications? This therapeutics letter looks at the evidence summarized in 11 different Cochrane reviews, and the best evidence on the topic is:

    • The evidence is weak (surprise anyone?) and the available RCTs have a high risk of bias
    • At best, about 1/10 patients will achieve any meaningful reduction in pain
    • Almost everyone has some side effects from these drugs
    • If there is going to be a benefit, you will see in within about 1 week
    • There does not seem to be any benefit in higher doses. (I think this is the most important takeaway, as I often see people on crazy escalating doses)

Bottom line: It might be reasonable to try these medicines, but start at a low dose, and recheck at 1 week if benefits outweigh side effects. If they don’t, stop the drug.

Black box on fluoroquinolones

FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together [available here]

So this isn’t research – it’s a notice of a new black box warning from the FDA. I am often skeptical of these warnings, as in some cases I think they have clearly done more harm than good (droperidol), but I think this one is worth knowing about. They say that “the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolone should be reserved for those who do not have alternative treatment options.” I would say this is pretty obvious, as there is no benefit of antibiotics in sinusitis and bronchitis. If a patient has a bad outcome and you are giving them a drug that has no chance of helping them, I would find that hard to defend.

Bottom line: Don’t use fluoroquinolones first in uncomplicated UTIs. Don’t use antibiotics at all in sinusitis or bronchitis.

But can we change our bad antibiotics habits?

Meeker D, Linder JA, Fox CR. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 315(6):562-70. 2016. PMID: 26864410

We know that antibiotics don’t help for the vast majority of acute respiratory tract infections, but for some reason people just can’t help themselves. Every patient I see in the ED with a cough for 3 days is already on azithromycin or amoxicillin. They come to the ED because they can’t understand why they aren’t getting better on antibiotics. They think they need something stronger. This is a randomized controlled trial trying to get doctors to smarten up. In a total of 243 different clinicians, they tried three different interventions: 1) automated reminders that antibiotics are inappropriate and alternate treatment suggestions 2) the requirement of an ‘antibiotic justification note’ as part of the permanent record, and 3) intermittent e-mails comparing the performance of various doctors. Each clinician was exposed to anywhere from 0 to 3 of the interventions. The control group (no intervention) decreased their prescribing rate by 11% – a good demonstration of the Hawthorne effect. The reminders did nothing. Requiring a justification and being compared to peers decreased inappropriate antibiotic use.

Bottom line: Sadly, simply giving physicians information is not enough to change their practice. We need to be shamed into change. Maybe I should stop writing about the evidence and instead walk around personally shaming people?

Again – we don’t listen to good advice

Rosenberg A, Agiro A, Gottlieb M. Early Trends Among Seven Recommendations From the Choosing Wisely Campaign. JAMA internal medicine. 175(12):1913-20. 2015. PMID: 26457643

I love the choosing wisely campaign – except that we know doctors love to ignore good advice. This is a retrospective look at a billing database (so not necessarily the most reliable data, although the conclusions are believable.) They looked at 7 items that were listed by choosing wisely as being of minimal or no benefit (such as pre-op chest x-ray in the absence of concerning history, or imaging of low back pain without red flags) and looked to see if the number billed for changed over a 3 year period after the recommendations. They didn’t. (OK, imaging for headache went down from 14.9% to 13.4% – not exactly a clinically important change). Horrendously, the use of antibiotics for sinusitis remained at 84%!

Bottom line: Physicians just don’t change their practice when presented with good evidence or advice. It does makes me wonder if I should stop sending these e-mails – as they are probably not accomplishing anything.

Police officer: “Sir, How high are you?” Pothead: “No officer, its ‘Hi, how are you’”

Tefft BC et al.  Prevalence of Marijuana Involvement in Fatal Crashes: Washington, 2010 – 2014. May 2016. Washington, DC: AAA Foundation for Traffic Safety. [free full text]

This is a report by the AAA Foundation for traffic safety. It retrospectively looked at a database from the Washington State Traffic Safety Commission. In Washington State, as many will know, marijuana became legal in December of 2012. This study looked at all motor vehicle collisions that resulted in death and the proportion who had THC (delta-9-tetrahydrocannabinol) in their blood on autopsy. They compared collisions in the 2 years before the new law to the 2 years after the law. Out of the total of 3031 fatal MVCs over 4 years, 303 (10%) involved drivers testing positive for THC. The percentage rose from 8.9% in 2013 (before the law) to 17% in 2014. Of the individuals with positive tests for THC, 39% also had alcohol on board, 16% had other drugs, and 10% had alcohol and other drugs (leaving 34% with only THC detected). There are some problems with this data, the biggest probably being that we don’t know what levels of THC correlate with being impaired. THC wasn’t measured in every case, and sometimes measurement was delayed. Also, the total number of fatalities didn’t increase, just the number with THC on board, so the marijuana could be a bystander rather than a cause of the collisions. However, the issue of impaired driving, and our lack of science to guide us, remains a huge issue as this popular legalization movement continues forward.

Bottom line: Don’t smoke and drive

Would you be surprised if this patient died?

George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. Journal of pain and symptom management. 51(1):108-19.e2. 2016. PMID: 26335763

I really hate adding work for our overly taxed triage nurses, who end up doing a lot of our screening. However, we are awful at recognizing patients with palliative care needs. This is a review, and I don’t think it is strong enough to completely overhaul triage systems, so I won’t go into the details, but they do conclude that palliative care screening is feasible. My favorite screening question is “would you be surprised if this patient died during this visit or in the coming month?” If no, they should probably have palliative care involved. Of course, the harder part of this equation is actually having adequate palliative resources for all the patients who need them.

Bottom line: Emergency medicine is all about dying patients. Palliative care should be an essential part of our mindset. You can have a much bigger impact by starting palliative care than you ever will handing out antibiotics for sore throats.

Epinephrine is safe in fingers – is that old news by now?

Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. The Journal of emergency medicine. 49(5):799-809. 2015. PMID: 26254284

This is a systematic review looking at the use of epinephrine in digital blocks. It should be stated up front that the conclusions are only good as the original studies – and they aren’t great. In a total of 30 studies, they identify 2797 blocks performed with epinephrine without any complications. They conclude that epinephrine is safe to use in digital nerve blocks in healthy patients. (Although, to be fair, it probably doesn’t help most of the time.)

Bottom line: This is probably another classic myth, although the data isn’t actually strong enough to definitely conclude safety.

CT first for the scaphoid?

Yin ZG, Zhang JB, Gong KT. Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures. Journal of orthopaedic trauma. 29(8):e245-52. 2015. PMID: 25756914

I hate cost-effectiveness studies. The results hinge on a huge number of assumptions that really can’t be confirmed. However, sometimes they provide some insight that can be interesting. In this study they compared the cost of working up scaphoid fractures using a number of different strategies, such as immediate CT, immediate MRI, MRI on day 3, bone scan on day 3, and x-ray at 2 weeks. Maybe counterintuitively, the immediate CT was the most cost effective approach followed by the immediate MRI. I am not sure that you can take these results to the bank, but it is a good reminder that there a number of costs that we often forget about. Although immediate CT seems expensive, to come to a follow-up visit the patient must miss work, pay for parking, and see another physician. Additionally, being in an unnecessary cast for 2 weeks could result in 2 weeks unnecessarily off work. It’s not time to change yet, but I wouldn’t be surprised if immediate definitive testing for the scaphoid became the standard in the future.

Bottom line: CT first for scaphoid fracture might actually be cheaper than standard practice.

Compassion and the good Samaritan study

Darley JM, Batson CD. “From Jerusalem to Jericho”: A study of situational and dispositional variables in helping behavior. Journal of Personality and Social Psychology. 27(1):100-108. 1973. [article]

This is a classic study from the psychology literature. It is a study of seminary students. Half were told they had to give a talk on the parable of the good Samaritan. The other half were told they had to give a talk on routine seminary jobs. Some students were told they were late for the talk and had to hurry, whereas others were told that they were on time. There was a plant on the way to the lecture hall: a man slumped in a doorway who moaned twice as the students walked by. Whether or not they had been thinking about the parable of the good Samaritan made no difference in whether or not they stopped. The only thing that influenced their decision to help was how hurried they felt. I see a clear connection to emergency medicine. Our job requires an incredible amount of compassion. However, simply thinking about compassion doesn’t seem to help. If we are rushed, we are less likely to be compassionate, whereas if we have time, we will use it. Unfortunately – how many people feel like they have a lot of free time in the emergency department? Managing our departments so physicians are not constantly run off their feet is probably a really good idea. (Of course, that is quite a reach from this research scientifically speaking – but it makes a lot of sense to me.)

Bottom line: Ensuring that physicians aren’t rushed might be crucial in increasing our ability to be compassionate on the job.

Cheesy Joke of the Month

I was sitting in a bar the other night when the waitress yelled out “does anyone know CPR?!”

I yelled back, “yeah, and I know the rest of the alphabet too.”

Everyone laughed. Well, except one guy.

#FOAMed of the month

How is it that one develops mastery? Cliff Reid provides some insight into deliberate practice in the context of getting his ass kicked.


Management of the Massive GI Bleed

A brief summary of the initial emergency department resuscitation of a patient with massive gastrointestinal bleeding


You are called urgently to resuscitation. Walking into the room, you recognize a familiar face. In fact, didn’t you discharge him home yesterday with epigastric pain that you attributed to his chronic alcohol use? Today’s diagnosis is not a mystery. There is already a puddle of blood on the floor, and he is quickly filling another emesis basin with bright red blood. A glance at the monitor reveals a heart rate of 135 and a blood pressure of 74/34…

Continue reading “Management of the Massive GI Bleed”

Balloon tamponade of massive GI bleeding

A brief summary of the procedure of balloon tamponade in massive upper gastrointestinal haemorrhage


You have been resuscitating the 62 year old man with a massive GI bleed from the previous post. You started your massive transfusion protocol and have him safely intubated. However, he continues to bleed, and you need to transfer him out of your small community hospital…

Continue reading “Balloon tamponade of massive GI bleeding”

Isoniazid overdose

A brief summary of the initial resuscitation of a patient with isoniazid toxicity


You get a patch from an EMS crew on route with a 3 year old boy in status epilepticus, with 5 minutes of tonic clonic seizure activity unresponsive to the first dose of midazolam. You gather your team and perform a quick pre-brief, reviewing everyone’s expected role, the algorithm you will follow, and the anticipated pediatric doses. You gather all the necessary pediatric equipment and have the broselow tape ready. You are feeling very confident, but when paramedics role through the door, you encounter a mother screaming about her child being poisoned. Apparently grandma is being treated for tuberculosis, and the pills were all over the ground. The child is still in an active tonic-clonic seizure as the paramedics transfer him to the resuscitation bay stretcher…

Continue reading “Isoniazid overdose”

Surviving the first 10 minutes (lecture notes for North York Emergency Medicine Update)

Lecture notes to accompany 2016 NYGH EM Update talk on performance under pressure and mental practice: Surviving the first 10 minutes

In this talk, we focused on mental practice as a technique to help improve our performance under pressure. For the full notes and references on performance under pressure and mental practice, see this blog post.

Mental practice First10EM.PNG

Mental practice evidence summary First10EM.PNG

We want to use mental practice to ensure that we have all the resources we need, in order to deal with the demands placed on us.

Demands greater than resources is a threat First10EM.PNG

Resources greater than demands is a challenge First10EM.PNG

We discussed three cases to demonstrate the role of mental practice:

In order to make mental practice work for you, you want a simple script that guides you through your approach to the patient. Most importantly, the script needs to be specific to you, taking into account your skills and your practice environment. Then, to practice, you should actually picture yourself in the resuscitation room and visualize not just the steps, but specifically how you are going to get each step done. Where in the room is the required equipment? How does the equipment work? How are you going to organize your team? Who is doing what, in what order?

I think this kind of dedicated practice, combined with the simplified action script for you to fall back on when under pressure, will ensure that you have the resources you need to meet the crazy demands of emergency medicine.