Interesting Studies About Learners in the Emergency Department

The following study results about learners in the ED are department specific for each study, though they offer a sense of general perspective on the issues at hand.

-  Medical students do not affect attending or resident productivity

- One resident with one attending will see more patients than the attending alone

- mid-level providers consistently see more patients in high and low acuity settings than residents

- In high acuity settings mid-level providers have lower RVUs than residents

- In low acuity settings, mid-level providers have higher RVUs per hour but lower RVUs per patient than residents

- EM interns increase the number of patients seen per shift over the course of the year. Other department interns or EM second years do not.

- EM residents see more patients and bill at higher acuity levels as they progress through residency

Feel free to leave any others in the comments.

The Scandal of Dabigatran – A Summary

We’ve been desperate for a more elegant solution to anticoagulation than rat poison for seemingly an eternity.  Now, we have them: direct thrombin and factor Xa inhibitors.  The studies supporting their use seem favorable.

But, as the old story goes – and as previously reported on this blog many times – Boehringer Ingelheim has been selectively reporting only the most favorable aspects of their flagship drug, dabigatran.  Increased cardiovascular events have been downplayed through study design not powered to detect a difference.  Issues with fixed dose therapy – and lack of a range of options for patients with renal impairment – rear their ugly head in multiple case reports.

Then, the most damning – the recent legal action reveals Boehringer Ingelheim, after selling dabigatran as not requiring monitoring nor having a reliable assay to monitor its effects, was hiding information on both counts.  There is, in fact, substantial individual-patient variability in dabigatran efficacy and bleeding risk, and the HEMOCLOT test is, in fact, a reliable method of measuring activity.  Review of internal documents shows employees were aware many patients might benefit from routine monitoring of levels – but this would eliminate one of its selling points (and cost savings) over warfarin.  These e-mails also specifically address the potential damaging effect on sales if said information were released in the scientific literature.

Clearly, yet another case where first-mover status into a lucrative market trumped patient-safety concerns.  If you wonder where the rampant skepticism regarding conflict-of-interest comes from on this blog – this is a beautifully flagrant example.

“Dabigatran: how the drug company withheld important analyses” (free fulltext)

Previous EM Lit of Note Posts:
Rivaroxaban Can Be Reversed, But Not Dabigatran” - Sept 2011
Scattering Tacks In The Road” - Jan 2012
Dabigatran — Uncharted Waters and Potential Harms” (Annals of Internal Medicine) - May 2012
Dabigatran - It's Everywhere!” - Sept 2012
Not-So Routine Surgery on Dabigatran” - Sept 2012
Dabigatran: Hidden Danger in the Home” - Nov 2012
Dabigatran & CES1 SNP rs2244613” - Mar 2013

MEdIC Series | The Case of the Absentee Audience

LLSAslideHave you ever been at a lecture where the audience didn’t seem in ‘sync’ with the speaker?  Or perhaps as a junior presenter, some of you may have been at a lecture or two that just didn’t seem to work. This month, we ask you to advise Dr. Xiu, a presenter who is experiencing this exact problem. Come out and discuss the Case of the Absentee Audience.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Absentee Audience

by Teresa Chan (@TChanMD)

The view from the lectern was less than inspiring. Dr. Nelly Xiu, a newly appointed Associate Professor, stood in front of a half filled lecture hall. Of the nearly forty residents and medical students who were supposed to be at the Emergency Medicine conference day*, only about half were physically at the talk. Nelly viewed the learners, watching them pull out their computers, smart phones, and the occasional journal, and wondered if any of them were mentally present.

At the end of her lecture, the tepid applause from the audience further reinforced her impression. Nelly was surprised when the chief resident, Andrew Smith, came up to chat with her after her lecture.

“Hey Dr. Xiu, good talk. Therapeutic Hypothermia is a really important topic,” he started. “I was wondering if you’ve ever thought about doing this topic as a workshop instead?”

Nelly looked at him, perplexed by his question. Clearly the students and residents had been wholly disengaged with her lecture, couldn’t he see that?

“Andrew, this was a mandatory class, and only 20 of the 40 learners on our teaching unit came. And then the half that did come were too busy texting and emailing to listen.”

“Well, I don’t think that’s fair.  A bunch of them are post-call, some of them were still rounding with their attendings, and some of them were sick. You’re right – this is mandatory – but sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.”

Nelly pondered this thought for a moment. If the word mandatory wasn’t enough to ensure learner attendance and attention, then what would she need to do to reach her audience?

Key Questions

  1. Andrew says: “…sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.  Is he correct in his statement? Why or why not?
  2. What are some issues that occur when you make a session ‘mandatory’?
  3. As a teacher, are there any preventative measures that you can use to prophylax against an absentee audience?
  4. What are some strategies that you might advise Dr. Xiu to use in her future sessions?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This month the two experts are:

  • Dr. James Ahn (@AhnJam) is an emergency medicine physician in Chicago, IL. He is the associate program director and medical education fellowship director at the University of Chicago. His areas of interest include curriculum development and competency testing.
  • Dr. Stella Yiu (@Stella_Yiu) is an emergency physician in Ottawa, ON, Canada.  She is an assistant professor in the Department of Emergency Medicine at the University of Ottawa. She is the brains behind the Flipped EM Classroom.

On August 1, 2014 the Expert Responses and Curated Community Commentary for the Case of the Absentee Audience will be posted.  Please comment below to join in the discussion.  Your comments will help to form the basis for the curated community commentary.

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Author information

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan

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Evidence against the cuts in Nursing Staff

Hola a tod@s, my dear friends!

Today I want to give diffusion to the
Opinion article (sorry, you should practice your Spanish this time) published by José Manuel Velasco in Enfermería Docente in 2013 and broadcast entirely in Seguridad del paciente y enfermero (patient and nurse security)

I give a summary, but it's worth that you read it whole.
"In an atmosphere of growing concern for the safety of health care, numerous studies have examined the relationship between nurse staffing and the results obtained.

Based on them, different Scientific Societies have spoken out about the health impact that produces a deficit in the relationship nurse/patient (n/p).

• Increase in iatrogenic complications.
• Increase in human errors.
• Delay in the weaning from mechanical ventilation.

• The rate of infection increased

Said in other ways:
•When the relationship nurse/patient (n/p) decreases, there is a considerable increase in times of critical processes as a result of the increase: increased medication errors, complications, wound infections, nosocomial infection.
•Patients who underwent surgery in hospitals with low ratios n/p are at a higher risk of developing complications avoidable as such as urinary tract infections, pneumonia, thrombosis, and pulmonary complications.
•Patients undergoing mechanical ventilation need more time for their weaning (disconnection of fan) when the n/p ratio decreases.

A large number of studies with large samples and published in high impact journals, alert in the same way about the consequences of inadequate planning of nursing staff and the relation between adverse events, death, costs and the number of nurses.
Based on these reports it can be asserted that a good qualitative and quantitative relationship of nurses reduces mortality and morbidity rates, also decreasing the stay average, the rate of readmission and consequently the costs of care.
Inexplicably, and immersed in an economic crisis that justifies everything, we have been observing daily significant reductions in allocations of professional nurses. Inexplicably I say because usually nobody is exposed to explain in details the reasons why these decisions were taken up before they run them. And because they are inexplicable from any point of view, both scientific, economic, and of common sense.

If in the absence of other arguments, there are exclusively economic reasons to justify that reduction and those decision-makers think that nursing staff reduction will save, it is a duty to launch an error and we must warning that, based on the extensive bibliography that documents this fact.

You may be eligible, at least, of"risky"the go ahead with proposals for reduction of staff of nurses under contrary to the recommended ratios".
Who has ears to hear...

Happy Friday!

Ketamine dosing in obese adolescents

Whilst ketamine is widely used in children of all ages, previous studies (Green et al, 2009) have shown that adverse events associated with ketamine are more common in adolescents (including airway adverse events and vomiting).

Additionally, there is a lack of clarity for calculating the ketamine dose in obese adolescent patients – should it be based on ideal body weight  (Wulfsohn, 1972) or standard mg/kg doses as most guidelines suggest? Standard paediatric guidelines don’t tend to include a max dose – so what are we supposed to do?

This study investigates the dose of ketamine required to achieve adequate sedation in adolescents.

Street MH, Gerard JM, A fixed-dose ketamine protocol for adolescent sedations in a pediatric emergency department, Journal of Pediatrics, 2014

Who was studied?

This was a prospective, observational cohort study.

The study included patients presenting to the Emergency Department aged between 12 and 18 years old and weighing greater than 35kg, who required procedural sedation. They had to meet criteria for ASA Class I or II.

Patients were excluded if they had: craniofacial, airway, and cardiorespiratory abnormalities, previous sedation-related events, neurological masses, or were undergoing an oral procedure.

There were 43 patients – mean age 13.9 years, mean weight 68.8kg, and mean BMI 24.4.

39.5% had a BMI greater than 25.

What was the intervention?

The normal sedation policy was was followed, with pre-oxygenation and ongoing physiological observations. No benzodiazepines or antiemetics were given before sedation.

50mg of IV ketamine was given to each patient (over 30-60 seconds) and then sedation was assessed. Further doses of 25mg IV ketamine were administered until adequate sedation was achieved.

Sedation was measured using the Ramsay Sedation Score (RSS), and ‘adequate sedation’ was when the RSS was 5 or greater.

All patients were managed with the same guidelines. However for data analysis, the patients were split into those with a BMI over 25 and those with a BMI of 25 or less. Data was collected to record the dose of ketamine required to achieve adequate sedation.

What were the measured outcomes?

The main outcome was provider satisfaction with sedation which was based on a 0-100 point scale rating.

Adverse events were noted during the procedure, and families were contacted at 12-24 hours post-procedure to grade their satisfaction and record any other adverse events.

Heights, weights, and BMIs were calculated for all patients.

What did the results show?

81.4% of the cohort achieved adequate sedation after just 50mg of ketamine. All the remaining subjects achieved adequate sedation following a further 25mg dose.

Mean sedation time was 27.4 minutes and mean time to discharge was 116.9 minutes. Time to discharge was shorter in the overweight group.

A similar proportion of people from both the overweight and non overweight groups achieved adequate sedation with the 50mg ketamine dose. Based on actual body weight, the overweight group received less ketamine per kg.

Satisfaction was the same between the groups immediately post-procedure, and also on follow-up. 95.3% of families were satisfied or very satisfied with the sedation.

Were these any ketamine side effects?

  • 2.3% (one patient) had desats which recovered with repositioning
  • 18.6% developed nausea during recovery
  • 14% vomited during recovery
  • 2.3% (one patient) developed agitation which required midazolam

There was no difference in adverse events between the two groups.

No patient required over 75mg of ketamine to achieve initial adequate sedation (but bear in mind that patients did require further doses during the procedure as top-ups). Those in the overweight group required a median dose of 0.79 mg/kg to achieve adequate sedation.

Ketamine dosing in obese adolescents is a poorly understood area. This study indicates that there is no need to give the standard 1-2mg/kg ketamine initially. A fixed dose of 50/75mg should be sufficient to achieve adequate sedation in the obese adolescent population.

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