Would you choose adenosine?

Comparing adenosine to calcium channel blockers in the management of SVT

Hi sir. My name is Dr. Morgenstern. That racing feeling in your chest… it’s something we call SVT. That just means that you heart is going too fast. I’m going to get it slowed down for you. All that silly stuff we just did – getting you to blow in a syringe and raising your legs above your head – that sometimes works, but honestly, I have never seen it work myself. It’s time to stop asking you to “bear down” and move on to using medications to slow your heart down. Right now, your blood pressure is fine and you have no other problems, so we have a few options.

Option number one is a medication that works about 90% of the time, but it causes a horrible feeling when it is given. Some people describe it as chest pain. Others say is feels like they are going to die. Most people tell me it is the worst thing they have ever experienced.

Option number two is a medication that works closer to 100% of the time and doesn’t cause any pain at all.

Which would you prefer?

Continue reading “Would you choose adenosine?”

EM Mindset: Not knowing

This post was written for the fantastic EMDocs.net EM Mindset series.  If you have not come across this series before, I strongly recommend checking it out. You can find it here. Thanks to Alex Koyfman and Brit Long for their edits. Continue reading “EM Mindset: Not knowing”

The conversation that extended my career

We all mistakes. It’s better to talk about them.

My heart is pounding. My stomach is in a knot. I can’t think straight.

I made a mistake. Continue reading “The conversation that extended my career”

Communicating diagnostic uncertainty

My transition from medical student to practicing diagnostician was marked by one key realization: doctors don’t make definitive diagnoses. Many think that we do. Our patients are certainly under that illusion. But even at the best of times, the physician’s job to to determine the probability of disease. Continue reading “Communicating diagnostic uncertainty”

Making it Stick

I don’t know how much of what I “learned” in medical school I have since forgotten. It is a lot. Probably more than I remember. I did great on exams, but then it was time to move on to a new semester and piles of new information took priority over the old. There was no time to review or consolidate.

At the time, this just seemed like the way that learning was done. It wasn’t much different from my undergraduate routine: cram for an exam, get the marks, and move on to another topic. This was the way medical school was structured. The expert educators behind my medical school curriculum obviously knew what was best for me – right?

But where is all that knowledge now? Why did it feel like I had to start all over again in residency? Why do the residents I teach now, fresh out of medical school and close to that wealth of information, so often struggle?

We spend so much time trying to learn medicine, but we never really learn how to learn. This post is basically a review of the book “Make It Stick” by Peter Brown, Roddy Roediger, and Mark McDaniel.1 I wish I had been given this book before starting medical school. Actually, it would have been more beneficial before starting university, or even high school. It explains clearly why learning seemed so easy but ephemeral. I had excellent marks throughout high school and university – but if you made me take an exam from any of my past courses right now, I would almost certainly fail. Is that really learning?

These are the key lessons I wish I had learned long ago: Continue reading “Making it Stick”

Survival lessons for the emergency department

Survival lessons from the book “Deep Survival: Who lives, who dies, and why” adapted for the ED

Deep Survival: Who Lives, Who Dies, and Why” by Laurence Gonzales is a book about life and death. It explores disasters – at the top of mountains, in the middle the ocean, in the most remote wilderness – and examines why some people live while others die. Gonzales concludes with book with some advice designed to help readers survive. As I read his advice, I was struck by how applicable it is to the practice of emergency medicine. These are his survival lessons, adapted for the ED: Continue reading “Survival lessons for the emergency department”

The HEAT Trial – The Skeptics Guide to Emergency Medicine

I got to sit down in person with Ken Milne this week while at the great SkiBEEM conference and talk about evidence based medicine. I know – life just can’t get much better. The episode of The Skeptics Guide to Emergency Medicine that we recorded about the HEAT trial was just released today. Make sure to check it out!

The episode is: SGEM#146: The HEAT is On – IV Acetaminophen for Fever in the ICU

 

I briefly covered the HEAT trial in the October 2015 edition of articles of the month:

Turning down the heat: can acetaminophen save lives?

HEAT trial: Young P, Saxena M, Bellomo R. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. The New England journal of medicine. 2015. PMID: 26436473 [free full text]

For some reason, people just love to hate on fever. It is present when people are sick, so it must be bad, right? We better rush to treat it. This is a randomized, double blind trial of 690 adult ICU patients with a fever and suspected infection, comparing acetaminophen 1 gram IV every 6 hours to placebo. Not surprisingly (unless you actually believed treating fever was helping patients) there was no difference in the primary outcome of ICU free days. There was also no difference in mortality at 28 or 90 days.

Bottom line: Tylenol is great, but it isn’t needed for febrile patients

 

Although this brief description is sufficient for spreading the word about new evidence, I think it is incredibly important to develop and in-depth understanding of the trials you use to shape your practice. The structured critical appraisal done on the SGEM is an amazing way to dissect this evidence and learn about EBM at the same time.

The most important question I get asked: how do I used this evidence? When just looking at the HEAT trial alone, I think the SGEM conclusion is appropriate: “We would agree with the authors’ conclusion that intravenous acetaminophen to treat fever in ICU patients thought to be due to an infection did not affect the number of ICU-free days.” However, this conclusion is pretty narrow. If you try to place this trial within the context of everything else we know about treating fever, I think it is safe to say that routinely treating infectious fever is unlikely to alter any clinically important outcomes. However, acetaminophen is safe and effectively manages symptoms, so it is very reasonable to use it for symptom control. (I certainly do.)