EM Mindset – Beyond the ED

Author: Anton Helman, MD, CCFP (EM), FCFP (@EMCases, EM Attending Physician, North York General) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

When I started practicing EM 16 years ago my mindset was a simple one: look for the most life-threatening diagnoses, settle on the most probable diagnosis, band aid the most urgent problems, and move the patient through the ED quickly. This approach seemed to work well most of the time. My chief was happy, and no one complained. But I soon found myself becoming unsatisfied with work and seeing many of the same patients return to the ED with the same issues again and again.

As I dedicated more time to EM education, I shifted my mindset to a more holistic one in which an open mind, better communication, and a longer view of how we can ensure better help for the patient after they leave the ED means a better experience for the patient – and staff, too.

The problem

Emergency Medicine has grown at an incredible pace as a specialty and we, the EM community, should be proud of what we have achieved. Nonetheless, we remain a “reactive” specialty in which fixing the most urgent acute illness or injury in the most efficient way possible, all too often trumps holistic patient care. This is understandable. Patient volumes have been increasing in Canada at a rate of 2-5% annually, and hospitals are under an enormous amount of pressure to minimize costs and resources. So our goal in treating an ED patient is often limited to returning them to their baseline status, moving them on, and getting to the next patient. We are very good at this, but we all know that returning the patient to their baseline will not necessarily prevent them from bouncing back with the same problem. Our research and education reflect this attitude: we focus on “hard” outcomes like short-term mortality and 30 day “serious event” rate. I often hear EM physicians teaching residents about the outcomes that “really matter”. We all too often neglect the important functional and mental outcomes: ability to perform ADLs, getting back to work, maintaining healthy relationships, etc.

I think it’s important to realize that it’s the most vulnerable populations who end up in the ED and who need the holistic care that we can provide most. As the population ages, older patients have accounted for an increasing proportion of the patients we see in the ED. Young adults with mental health crises and addiction issues are also on the rise. And with growing income inequality, we see poorer health outcomes for those with low incomes; this trend is unlikely to cease.

Proposal for an EM mindset: Enhanced communication, open minded compassionate care, and thinking beyond the walls of the ED

We are first and foremost doctors, and as doctors our job is to provide compassionate care for patients. In the face of some toxic work environments where specialties in their silos “push back” at each other to avoid having to take care of patients, we need to constantly remind ourselves that we have the privilege to work as doctors to improve the lives of our fellow humans. We should be working together for this common goal. The sooner the medical culture embraces this, the sooner we will be able to provide holistic care to our patients, not to mention developing improved work satisfaction for ourselves. In the U.S. EM has recently been ranked as the medical specialty with the highest burnout rate, and I believe that with a change in mindset we can reverse this worrisome statistic. The ED is the hub of the hospital and health care system where almost all specialties intersect. EM is perfectly situated to impact the general medical work culture positively.

Emergency medicine should be an outward facing discipline

The ED is the gateway into the health care system for millions of people and so literally plays a central role in the health of communities. One of the disadvantages of EM is that we rarely get to follow up with our patients. Seeing illness develop over time not only gives us a deeper understanding of pathologic processes, but helps us understand a patient’s needs more deeply. We need to be more aware of the circumstances leading up to and following an ED visit. Transitions of care need to be seamless, especially for vulnerable populations. We have an opportunity to extend the influence of EM beyond the walls of the ED and really impact important patient outcomes and efficiency of care, as well as improve population health in general.

Many EM residency programs have no training in communication and compassionate care, which is a major oversight in my opinion. Improved patient experience has been linked to improved patient outcomes in more than one hundred studies. Simply sitting down to interview patients, giving them time to tell their story, looking them in the eyes rather than at their chart or your computer screen, addressing their concerns and fears, and giving them a chance to ask questions make them feel like they are being taken care of as a human rather than a disease or illness. There are simple quick things we can do for our patients in the ED that could have lasting positive health effects like simply stating to all smokers who present with a smoking-related illness “your current illness is related to your smoking. Quitting smoking is the best thing you can do for your health, and we can offer you some resources to help you quit when you’re ready to do so”. Even if only 10% of the patients you say this to end up quitting smoking, you’ve probably prevented a whole lot of smoking-related illness that might end up back in your ED requiring huge resources. If we recognize the importance of patient experience (as opposed to patient satisfaction scores), our mindset will change from just fixing the most urgent problem to healing our patients.

I believe that we have a responsibility as doctors in general, and as EM specialists seeing patients at their most vulnerable moments in particular, to provide compassionate care and preventative advice and resources that can have positive effects beyond the walls of the ED. We can help motivate patients to take better care of themselves in a supportive manner and point them in the right direction.

Let’s grow EM as a specialty in which the art of medicine shines

We suffer from the delusion that near everything in medicine can be labeled, categorized, protocolized, and proven – that there is a “right” answer for everything. While there is certainly value to these attempts at making sense of all the data that we are bombarded with, emergency physicians need to embrace uncertainty; flex to new situations, issues, and problems that arise; and be open to alternate approaches, open to our patients’ points of views, open to the idea that one theory replaces another in science; and ultimately embrace that there is no such thing as “the right thing to do”. By adapting a mindset of enhancing our communication skills to improve the patient experience, keeping an open, flexible mind, and learning more about how we can help our patients after they leave the ED, we can provide true patient-centered care that will impact the overall health of our patients in the long run. Your patients will remember the positive impact you had on their health decades later. We have an opportunity in EM not only to impact morbidity and mortality in the traditional sense, but to have deep lasting positive impact to help our patients live their lives to the fullest, while setting an example for other specialties to work together instead of against each other, and enhance our satisfaction for the great work we do


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Quick-Hit Ultrasound Probe: Ectopic Pregnancy

Author: Mark Gonzales DO, MPH, FAAEM (Attending Physician and Ultrasound Director, Carolinas HealthCare System – University Hospital, Charlotte, NC) // Edited by: Stephen Alerhand, MD and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

You are just wrapping up your resuscitation of a patient with acute respiratory failure. As you are about to leave the room, a concerned RN interrupts you. He is concerned about a 23-year-old female patient who presents with acute-onset lower abdominal pain. She is G3P0030 and had received Methotrexate for a presumed ectopic pregnancy 24 days earlier. She has had no significant vaginal bleeding or discharge today, but reports having had moderate vaginal bleeding after her Methotrexate treatment. Her two prior pregnancies terminated due to spontaneous abortion. The patient is afebrile with a blood pressure of 104/66, heart rate of 60, respiratory rate 18, and oxygen saturation of 100% on room air. She appears moderately distressed and has significant bilateral lower abdominal tenderness on exam.

You place her in a supine position, grab your ultrasound machine and perform a transabdominal assessment of the pelvis with the curvilinear probe:


You note the presence of free fluid in both the sagittal and transverse views. You also note an abnormality in the right pelvis that catches your eye, so you zoom in on this structure:

Given the patient’s history, the mass in the image concerns you for an ectopic pregnancy, and with the previously noted free fluid in her pelvis, you slide the probe to the right upper quadrant for a view of Morison’s pouch:

With evidence of free fluid in Morison’s pouch, you put down the probe, ask the nurse to start two large bore IV’s, and head to your desk, this time uninterrupted. You place a STAT page for the on-call OB/Gyn as well as orders for STAT blood products. You also have the secretary notify the Operating Room. The patient’s preliminary labs show a positive urine pregnancy test and a Hb/Hct of 12.7/40. Her blood pressure and heart rate remain stable. The OB/Gyn consultant comes downstairs, reviews your images, and agrees with your assessment. The patient is taken to the OR for an emergent laparoscopy, where 750 cc of hemoperitoneum is evacuated. The patient also undergoes a right salpingectomy due to ruptured ectopic pregnancy. The OB/Gyn later tells you that the patient’s Hb/Hct dropped to 7.6/24 intra-operatively, but she expects the patient to do well. You write your ED nurse a compliment card to commend him for the heads-up and continue your shift.

Six take-away points for this case:

1) In one study, the presence of non-traumatic free fluid in Morison’s pouch in a female with suspected ectopic pregnancy was 99.5% specific for ruptured ectopic pregnancy requiring operative intervention, having a positive likelihood ratio of 112.1

2) Failure of methotrexate treatment for ectopic pregnancy is uncommon. In a systematic review that included 26 observational studies of 1,300 women with ectopic pregnancy, the success rate of methotrexate was 88% for single dose therapy and 93% for multiple dose therapy.2

3) Obstetric and abdominal US are must-know applications for all emergency physicians. This is a classic example demonstrating the power of bedside ultrasound in its ability to meaningfully affect patient care for a time-sensitive diagnosis in the Emergency Department.

4) Remember that young patients may be able to compensate and maintain an adequate heart rate and blood pressure in the setting of ruptured ectopic pregnancy and intravascular volume depletion. Do not let normal vital signs fool you.

5) For further interest, ACEP recently released a new iBook in 2016 titled “Point-of-Care OB Ultrasound.”3

6) Don’t forget to thank your nurses.

References / Further Reading

1) Moore C, Todd WM, O’Brien E, Lin H. Free fluid in Morison’s pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007 Aug;14(8):755-8.
2) Tulandi T. Ectopic pregnancy: Choosing a treatment and methotrexate therapy. UpToDate. 27 Mar 2017.
3) Jones R and Goldstein J. “Point-of-Care OB Ultrasound.” First Edition. American College of Emergency Physicians, 2016. iBooks. https://itun.es/us/o1C4eb.l

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ToxCard: GI Decon

Author: Peyton Jones MD  (Medical Student, Emory University School of Medicine) // Edited by: Cynthia Santos (Senior Medical Toxicology Fellow, Emory University Hospital), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)


29 y/o female with PMH of epilepsy and depression presents to the ED 45 minutes after ingesting 50 doses of sustained-release carbamazepine 400mg tablets in a suicide attempt.


What are the options for GI decontamination for poisoned patients?


The options for GI decontamination for poisoned patients are activated charcoal, gastric lavage and whole bowel irrigation.

Activated charcoal (AC) absorbs toxins via weak intermolecular (Van der Waals) forces and prevents absorption by the GI tract.

  • AC should be given within one hour of ingestion but may be given later in anti-cholinergic ingestions resulting in delayed gastric emptying. AC is NOT an option in overdoses of heavy metals such as arsenic and iron, lithium, alcohols, acids, or alkalis. The charcoal will not bind to these substances (1).

Activated charcoal dose:

  • <1 year of age: 0.5-1.0 g/kg (typical dose ranges from 10 to 25g)
  • Children 1-12 years: 0.5- 1g/kg (typical dose ranges 25 to 50g)
  • Adults: 1g/kg (typical dose ranges from 50 to 100g per dose)
  • Multidose activated charcoal (MDAC) is recommended for drugs that have high enterohepatic circulation. Multiple-dose activated charcoal involves the administration of more than 2 doses of oral AC to enhance elimination of drugs.
  • MDAC is recommended for life-threatening ingestions of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. With all of these drugs there are data to confirm enhanced elimination, though no controlled studies have demonstrated clinical benefit. (2)
  • Although volunteer studies have demonstrated that MDAC increases the elimination of amitriptyline, dextropropoxyphene, digitoxin, digoxin, disopyramide, nadolol, phenylbutazone, phenytoin, piroxicam, and sotalol, there are insufficient clinical data to support or exclude the use of this therapy in a position statement by AACT and EAPCCT.(2)
  • The use of multiple-dose charcoal in salicylate poisoning is controversial and data from poisoned patients are insufficient presently to recommend the use of MDAC for these patients.(2)
  • Absolute contraindications to charcoal include unprotected airway, intestinal obstruction or perforation, and decreased peristalsis.

Whole bowel irrigation (WBI) refers to the administration of osmotically balanced polyethylene glycol electrolyte solution to induce liquid stool and mechanically flush pills, tablets, or drug packets from the GI tract.

WBI Dose:

  • 9 months- 6yrs: 500mL/hr
  • Ages 6-12 yrs: 1000mL/hr
  • >12 years of age: 1500-2000mL/hr
  • Continue giving solution until the rectal effluent is clear.
  • In a position statement by AACT and EAPCCT WBI should not be used routinely in the management of poisoned patients. No controlled clinical trials have been performed and there is no conclusive evidence that WBI improves outcome. WBI may be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs.(3)
  • There are insufficient data to support or exclude the use of WBI for potentially toxic ingestions of iron, lead, zinc, or packets of illicit drugs; WBI remains a theoretical option for these ingestions.
  • A single dose of AC prior to WBI does not decrease the binding capacity of charcoal or alter the osmotic properties of WBI solution. However, administration of AC during WBI does appear to decrease the binding capacity of charcoal.
  • WBI is contraindicated in patients with bowel obstruction, perforation, ileus, and in patients with hemodynamic instability or compromised unprotected airways.(3)

Gastric lavage (GL) refers to the passage of a large bore OG tube followed by repetitive instillation and aspiration of small aliquots of fluid in an attempt to aspirate pill fragments or toxins from the stomach. This is what the public refers to as stomach pumping.

  • GL should be considered in situations where a patient has ingested a life-threatening amount of a poison and the lavage can take place within 60 minutes of ingestion.(4)
  • Contraindications for GL include a compromised, unprotected airway and presence of GI hemorrhage or perforation. Relative contraindications include a corrosive substance, hydrocarbons, aluminum phosphide or in overdoses where there is an effect antidote as it is unnecessary.
  • The benefit of gastric lavage has not been proven in randomized controlled studies although studies have shown that those treated with gastric lavage versus just activated charcoal had increased rate of intubation, ICU admission and aspiration pneumonia. (4)


Main Point:

The types of GI decontamination include activated charcoal, whole bowel irrigation, and gastric lavage. Activated charcoal is used within one hour of ingestion and is effective for most ingestions. Exceptions include caustic acids and alkalis, alcohols, lithium, and heavy metals (e.g. iron, arsenic).  Multidose activated charcoal can be used in life threatening ingestions of carbamazepine, dapsone, phenobarbital, quinine or theophylline. Whole bowel irrigation is used to mechanically flush pills (especially extended release drugs), tablets, or drug packets from the GI system. Activated charcoal and whole bowel irrigation would be useful in this patient. Gastric lavage can be considered in a potentially life-threatening ingestion and the procedure can be completed within 60 minutes of the ingestion.

References/Further Reading:

  1. Olson, K. Acitvated Charcoal for Acute Poisoning: One Toxicologist’s Journey. J Med. Toxicol (2010) 6: 190-198.
  2. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999;37:731-751.
  3. Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists.Tenenbein M. J Toxicol Clin Toxicol. 1997;35(7):753-62.
  4. Vale J et al. Position paper: gastric lavage. American Academy of Clinical Toxicology. J Toxicol Clin Toxicol. 2004;42(7):933

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Myths in EM: Is Head CT Needed Before LP in all Adults with Suspected Bacterial Meningitis?

Authors: Michael D. April, MD, DPhil, MSc (EM Staff physician at SAUSHEC) and Brit Long, MD (@long_brit, EM staff physician at SAUSHEC) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

A 22-year-old male presents with headache and fever for the last two days. When he woke this morning, his headache was much worse. The patient has no PMH or allergies, and his VS include T 38.2 C, HR 105, BP 132/78, RR 22, Sat 98% on RA. His neurologic exam is non-focal, and he will answer questions appropriately. However, his neck is quite stiff. You are strongly considering meningitis, and you realize the patient will need a lumbar puncture (LP). You put your orders in for CT and LP with IV ceftriaxone. But does the patient need a CT before his LP?

Bacterial meningitis is a deadly CNS infection. Mortality can reach 15-21% even in patients receiving antibiotic therapy.(1,2) A lumbar puncture (LP) with cerebrospinal fluid (CSF) analysis is considered gold standard.(3) If this is not completed quickly before or shortly after antibiotics, it can be difficult to obtain an organism on culture.(4) However, delay in antibiotics is dangerous and drastically affects survival.(5-7)

LP is essential for CSF in the evaluation for meningitis, but there is concern for brainstem herniation in the setting of brain edema and increased ICP.(8) CT provides a reliable evaluation for mass effect,9 and many assume that herniation can be prevented by abstaining from LP in the setting of mass effect.

Myth: Cerebral imaging with CT before LP improves survival in suspected meningitis through identifying patients who should not undergo LP due to increased ICP from mass lesions.

Is this important?

The gold standard diagnostic study for bacterial meningitis is CSF obtained by LP.(3) CSF is important in ensuring adequate treatment and diagnosis.(4) Rapid antibiotic is necessary to avoid patient morbidity and mortality,(5-7) and LP is a vital component of the evaluation.

One major concern that patients with brain edema or lesions causing intracranial mass effect may experience lumbar puncture-induced brainstem herniation.(8) CT provides physicians with a reliable means of identifying brain lesions causing mass effect.(9) The assumption is that by avoiding LP in patients with mass effect, herniation may be prevented.

The Myth

Neuroimaging before LP optimizes survival for patients with suspected bacterial meningitis by identifying individuals with potential mass effect and herniation.

Why is it important?

Brainstem herniation can result in death or profound neurologic morbidity.(10) CT before LP in every patient with suspected bacterial meningitis could be considered safe practice. However this strategy has its own consequences, including radiation exposure and increased cost.(11,12) Even more important is the potential delay in antibiotics with head CT before LP.(5-7)

Several studies have tried to identify patients in need of pre-LP head CT.(13,14) The IDSA recommends a diagnostic pathway using selective CT in those patients with characteristics suggesting risk for post-lumbar puncture brainstem herniation.15 Yet these guidelines are highly controversial.(16) This post will provide an overview of the relevant primary literature concerning the need for head CT before LP in suspected meningitis.

A Little Lesson in History…

Most authors attribute the first description of the LP to Heinriche Quincke in 1891.(17) Papers published as early as 1896 reported peri-procedural deaths in patients with presumed intracranial lesions, though they note the challenges of distinguishing causation versus correlation.(18)

In 1938 Geoffrey Jefferson proposed a mechanism by which LP might precipitate brainstem herniation. He argued that in patients with intracranial lesions causing mass effect, the CSF exerts a protective upward buoying effect on the brainstem. He suggested that the brainstem may herniate downward through the foramen magnum if CSF is removed.(19) This paper was an important milestone by suggesting a causative relationship between LP and herniation.

Post-Lumbar Puncture Brainstem Herniation in Patients with Mass Effect Lesions

Several observational studies published since the 1950s evaluated outcomes in patients thought to have elevated ICP who underwent LP. These papers are often cited when discussing risk of LP,(8) but these studies require several considerations. The first major point is these studies are before CT was commonly used, and authors relied on clinical suspicion of tumor,(20,21) histological verification of tumor by CSF analysis or autopsy,(20,22) or papilledema.(20,21,23-25) These criteria comprise patients with many different pathologies, and papilledema can occur in conditions without mass effect (like idiopathic intracranial hypertension, a disease in which LP is needed for diagnosis and treatment).(26)

The risk of post LP neurologic decline thought to be due to herniation varied from 0 to 6.2% in these studies.(23-25) Time to neurologic decline also varied, from 5 minutes(24) to 24 hours, which calls into question the causative relationship of LP and decline with herniation.(20-22,24) Patients not undergoing LP may also experience neurologic decline with presumed intracranial mass.(21)

As these studies predate CT use in today’s medical era, extrapolating these data evaluating the risk of LP and herniation with mass effect to today is difficult. When CT became more readily available for use, physicians accepted the premise that patients with potential intracranial lesions were at higher risk for LP complications based on older literature. Thus, more definitive study was difficult, with data largely consisting of case series.(9)

Bottom Line: While data are limited to historical observational studies from the pre-CT period, there may be a small risk (~1-2%) that LP may be associated with neurologic decline in patients with intracranial mass effect lesions.

Post-Lumbar Puncture Brainstem Herniation in Bacterial Meningitis

Patients with bacterial meningitis may be at higher risk than those with mass effect lesions for herniation if they undergo LP. One cases series from 1956-1962 reported herniation in 9 of 175 patients who underwent LP. Four of these patients demonstrated cerebral edema, but no other anatomic abnormalities in the other patients were found.(27) Another cohort of 86 patients with meningitis who underwent LP reported herniation in 8.1% of patients.(28) These results question whether neuroimaging can identify patients with bacterial meningitis at greatest risk for herniation after LP. Several pediatric studies discuss cases of post-LP herniation in patients with normal imaging.(29,30)

Can deferral of LP prevent brainstem herniation? While this seems likely on first inspection, the literature suggests the relationship of procedure and poor outcome is not clear cut. One patient in the case series discussed above experienced herniation before LP.(27) Another study evaluating a head imaging decision rule derivation found 2 patients herniated even though they never underwent LP.(14) The pediatric literature again provides several cases of patients with meningitis who experienced herniation before LP.(29)

Patients with bacterial meningitis may be at risk for herniation, though imaging may not be able to identify those patients at risk. Bacterial meningitis is rare (1.7% of ED patients who undergo LP),(14) especially with the pneumococcal conjugate vaccine.(31)

Bottom Line: Patients with bacterial meningitis may be at higher risk than patients with intracranial mass effect lesions for brainstem herniation (8.1%), but it is not clear if deferring LP in patients with CT-diagnosed cerebral edema and mass effect decreases this risk.

Decision Rule Derivation Studies

Many professional societies continued to recommend CT before LP to evaluate for mass effect lesions in the early 2000’s, despite the limitations in data.(9,32,33) Two studies sought to balance radiation exposure(12) and delay in antibiotics(5-7) versus identifying patients with potential risk for post LP herniation due to mass effect from intracranial lesion. These studies sought to derive decision rules that selectively image patients with clinical features associated with abnormalities found on CT.

Gopal et al. investigated consecutive ED patients requiring LP in the ED for any indication. Investigators enrolled 111 of 113 consecutive patients, all with preceding head CT.(13) They identified three predictors for abnormality on head CT: altered mental status, focal neurologic abnormality, and papilledema. Authors stressed that one of these alone would not be accurate in predicting head CT abnormality, but the three items together could serve as a screening tool. Patients with none of these characteristics had a negative likelihood ratio (LR-) for any CT abnormality of 0.0 (95% CI 0-0.6). The presence of one or more characteristics yielded a positive likelihood ratio (LR+) of 1.6 (95% CI 1.2-1.9). Interestingly, authors also asked physicians to predict the likelihood of intracranial lesion based on clinical suspicion, which demonstrated LR+ 18.8 (95% CI 4.8-43) and LR- 0.0 (95% CI 0.0-0.7), suggesting clinical gestalt may be better than a decision rule.(13)

A study conducted by Hasbun et al. focused on ED patients undergoing evaluation for suspected bacterial meningitis.(14) They enrolled 301 patients regardless if they underwent CT or LP. 235 (78.1%) underwent head CT, and this group is what the authors used to derived their decision rule. They found age >59 years, immunocompromised state (HIV/AIDS, immunosuppressive therapy, transplant), history of CNS disease (known mass lesion, stroke, focal infection), seizures in the past week, and various neurologic examination abnormalities to predict any abnormality on head CT. The absence of any of these criteria resulted in LR- 0.1, while the presence of one or more criteria provided LR+ 2.0.(14)

Bottom Line: Patients with absence of any high-risk characteristics (age >59 years, immunocompromised state, history of central nervous system disease, seizures in the past week, and various neurologic examination abnormalities) have a LR- of 0.1 for any CT abnormality.

Limits of Decision Rules

Using a decision rule for evaluation in patients with bacterial meningitis has been advocated in the literature.(33-35) The IDSA recommends the rule by Hasbun et al. in determining the need for head CT before LP.(15) However, the Hasbun and Gopal studies have important limitations.(13,14)

1. Both rules demonstrate poor specificity, as the Hasbun et al. rule has a specificity of 52%, and importantly, this specificity refers to detecting any head CT abnormality. However, physicians should be concerned with head CT abnormalities possessing mass effect.(8) The cohort in the Hasbun study identified 4 patients in whom providers deferred LP, and all were decision rule positive. If specificity is recalculated based on these patients, specificity decreases to 41.6%, which suggests over half of patients not requiring head CT before LP will undergo imaging if the physician relies on this rule.

2. A second issue is the calculation of test characteristics using only patients who had head CT. Most physicians will apply the decision rules to broader population of patients who undergo CT. While most patients who did not receive CT in these studies were likely well appearing and may have not met study criteria, we do not know based on the reported data.

3. The Hasbun and Gopal investigations are derivation studies, and neither has been validated to this point. Both should have undergone validation in a different site and patient population. Validation studies ideally rely on measurement efficacy performed by clinicians, not investigators.(36) Just as an example, the literature discusses important expectations for validation studies for other disease processes, such as subarachnoid hemorrhage.(37)

Bottom Line: There as several limits to these decision rules that seek to determine the need for head CT before LP, and they have not been validated.

Head Imaging and Patient Survival

No study has explored decision rule impact on definitive patient outcomes. Conducting studies evaluating decision-rule based imaging against CT before LP or LP alone would be difficult due to expense and rarity of these poor patient outcomes in today’s medical era. Gopal et al. found 2 of 3 patients had positive CSF cultures and did not receive antibiotics prior to LP and CT.(13) Hasbun et al. found patients receiving head CT had a delay in antibiotics as well (close to one hour greater time to receipt).(14) Importantly, delay in antibiotics may be associated with 30% increase in mortality per hour in patients with meningitis.(7)

Swedish guidelines in 2009 were revised by removing the “impaired consciousness” portion of the criteria for obtaining a head CT before LP. Since that time, a reduction in door-to-antibiotic times and reduction in mortality (11.7% to 6.9%) have occurred.(16,38) These highlight the importance of antibiotics if meningitis is considered, especially if CT will be obtained.

Bottom Line: Swedish data reports shortened door-to-antibiotic times and improved survival among patients with bacterial meningitis after modifying criteria for CT before LP.

Case Conclusion:
You decide to perform a LP without CT, as the patient does not meet criteria for head CT. You provide 2g ceftriaxone IV after the LP is completed. The CSF results are concerning for meningitis, and you admit the patient.

Key Takeaways:

– The best available evidence suggests some association between LP and brainstem herniation in patients with intracranial mass effect lesions.
– However, this risk is small, and there is no evidence that deferring LP prevents herniation in patients with these lesions.
– Decision rules that attempt to identify patients most likely to have intracranial lesions with risk for post-LP herniation have several limitations and have not been validated.
– Patients with significant pre-test probability for intracranial mass effect lesion or bacterial meningitis based on clinical assessment should receive head CT.
– Antimicrobials are required if meningitis is suspected.
– Concern for meningitis warrants antibiotics before CT if imaging will be obtained.

References/Further Reading:

1. Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med, 2011; 364: 2016-25.
2. van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, and Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med, 2004; 351: 1849-59.
3. McGill F, Heyderman RS, Panagiotou S, Tunkel AR, and Solomon T. Acute bacterial meningitis in adults. Lancet, 2016.
4. Michael B, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, et al. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J, 2010; 27: 433-8.
5. Aronin SI, Peduzzi P, and Quagliarello VJ. Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing. Ann Intern Med, 1998; 129: 862-9.
6. Proulx N, Frechette D, Toye B, Chan J, and Kravcik S. Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM, 2005; 98: 291-8.
7. Koster-Rasmussen R, Korshin A, and Meyer CN. Antibiotic treatment delay and outcome in acute bacterial meningitis. J Infect, 2008; 57: 449-54.
8. van Crevel H, Hijdra A, and de Gans J. Lumbar puncture and the risk of herniation: when should we first perform CT? J Neurol, 2002; 249: 129-37.
9. Gower DJ, Baker AL, Bell WO, and Ball MR. Contraindications to lumbar puncture as defined by computed cranial tomography. J Neurol Neurosurg Psychiatry, 1987; 50: 1071-4.
10. Duffy GP. Lumbar puncture in the presence of raised intracranial pressure. Br Med J, 1969; 1: 407-9.
11. Centers for Medicare and Medicaid Services. Physician Fee Schedule. 2015, Baltimore: C.f.M.a.M. Services. Available from: http://www.cms.gov/. Accessed 4 October 2016.
12. Brenner DJ, and Hall EJ. Computed tomography–an increasing source of radiation exposure. N Engl J Med, 2007; 357: 2277-84.
13. Gopal AK, Whitehouse JD, Simel DL, and Corey GR. Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med, 1999; 159: 2681-5.
14. Hasbun R, Abrahams J, Jekel J, and Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med, 2001; 345: 1727-33.
15. Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis, 2004; 39: 1267-84.
16. Glimaker M, Lindquist L, Sjolin J, and Working Party of the Swedish Infectious Disease Society for Bacterial CNSI. Lumbar puncture in adult bacterial meningitis: time to reconsider guidelines? BMJ, 2013; 346: f361.
17. Frederiks JA, and Koehler PJ. The first lumbar puncture. J Hist Neurosci, 1997; 6: 147-53.
18. Furbringer P. Plotzliche Todesfalle nach Lumbalpunktion. Centralblatt fur Innere Medicin, 1896; 17: 1-8 [German].
19. Jefferson G. The tentorial pressure cone. Arch Neurol Psych, 1938; 40: 857-76.
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The post Myths in EM: Is Head CT Needed Before LP in all Adults with Suspected Bacterial Meningitis? appeared first on emDOCs.net - Emergency Medicine Education.

The Mentoring Process in Emergency Medicine – Part 2

Authors: Brit Long, MD (@long_brit, EM Staff Physician at SAUSHEC) and Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) // Edited by: Gus M. Garmel, MD, FACEP, FAAEM (Clinical Professor (Affiliate) of EM, Stanford University, Former Co-Program Director, Stanford/Kaiser EM Residency, Senior Emergency Physician, TPMG, Kaiser Santa Clara)

Case 1: The intern continues to do well. She and her mentor have been meeting monthly to discuss difficult scenarios encountered (clinical and non-clinical). The mentor has also found a potential research project for the intern.  What are the next stages in the mentor/mentee relationship, and how do they continue this success? 

Case 2: The junior faculty member has been in contact with a senior physician at his new institution. They have a meeting this week, and he sent him his CV. What should the mentee focus on or bring up at the meeting, and what should be discussed?

In part 1 of this series, we provided a foundation for mentoring including a definition, participants, goals, responsibilities, pearls and pitfalls. In part 2 we will explore four stages of mentoring, while reviewing several key aspects of mentoring.

Let’s get started…

Setting up the first meeting requires several considerations. First, schedule 30-60 minutes for the initial meeting. Both the mentor and mentee should discuss their own backgrounds, interests, and hobbies (time permitting), and exchange contact information including the preferred means of communication. Goals and objectives should be discussed to get a sense if the relationship seems promising and is to continue. The mentee should provide a copy of his/her CV before the meeting, which the mentor can review before the meeting (or evaluate at the time of the meeting if he/she is unable to do this in advance). During the first meeting, expectations and definitions of success should be clearly explained. The mentee should identify short- and long-term goals, with several areas of interest that might be conducive to collaboration or as a team. Following this, future meetings should be scheduled.  This can be difficult given EM schedules, but recurring contact and meetings are key to continue relationship development.

Mentoring Stages

Mentoring can be broken into four stages, with each reflecting the mentee’s learning and development needs. These stages can blend, and roles listed are not exclusive to each specific stage. These stages include: prescriptive, persuasive, collaborative, and confirmative.

  1. Prescriptive: The initial stage often occurs when the mentee has limited experience in either the field, organization, or institution. The mentee will depend heavily on the mentor for support and further instruction, and the mentor primarily coaches, teaches, and motivates the mentee, for whom building self-confidence is important. More time is required in this stage to ensure that a strong foundation is laid for a successful relationship. The mentee often soaks in new information provided, whether it be knowledge, mentor experiences, or cases.
  2. Persuasive: This stage entails the mentor persuading the mentee to investigate questions and seek challenges, as opposed to receiving them directly from the mentor. The mentee generally possesses more experience in their field than mentees in the prescriptive stage, but still requires direction from the mentor, including encouragement to seek opportunities for more learning and research. The mentor may suggest new strategies, questions, and challenges to the mentee. In this stage, the mentor functions as a counselor and guide. As the framework has been established in the prescriptive stage, the relationship now grows with sharing of experiences.
  3. Collaborative: The mentee now has experience and the ability to work with the mentor jointly to solve problems and communicate on a more equal basis. Career guidance is vital in this stage for the mentee, who is now more independent. The mentor may allow the mentee to function more independently or take the lead on joint projects, functioning as a career advisor and role model.
  4. Confirmative: This is an important stage for the relationship, as the mentee has developed and matured as a professional. The mentee often has a great deal of experience, mastering several aspects of the profession. The mentor plays a significant role as a sponsor, which entails offering advice and encouragement in career decisions.

Importantly, the relationship with a mentor may not start at the same place for different mentees, based on skill set, experiences, and needs. The relationship is not static can move back and forth between different stages, depending on what is needed. The mentor and mentee should consider several aspects: the mentee’s knowledge and abilities, the mentee’s level of experience, and the type and amount of guidance and support the mentee requires. Stages often overlap or mix in the mentoring relationship.  The mentor and mentee need to continually evaluate the relationship during its evolution to ensure it continues to develop and meet both parties needs and objectives.

Case 1: The mentor and mentee seem to be in the prescriptive stage, perhaps moving into the persuasive stage, as the mentee is relying on the mentor for support and instruction. However, with the baseline relationship formed, the mentor can now challenge the mentee, as well as act as counselor and guide.

Case 2: Even though the relationship has yet to formally start, the prospective mentee possesses a great deal of experience and ability to work collaboratively with the mentor. Due to the knowledge and skills of each participant, the relationship may begin at a more advanced stage (such as the collaborative stage). The mentee likely requires guidance related to aspects of the institution, such as politics, workload, and culture.

Building Skills and Optimizing the Relationship

Several aspects of the relationship can enhance the mentor and mentee’s growth. Location is important, with privacy, comfort, and time vital aspects. A meeting over coffee or food is a good excuse or opportunity to interact. Seek to utilize the most comfortable area, which should be convenient to both parties (especially the mentor), whether an office setting, cafeteria, or coffee shop. There may be a tradeoff between privacy and access to food, which should be factored in to the decision of where to meet. The meeting space is important because it can create an intimidating environment. For example, a large desk can act as a barrier. Also consider personal space: too close or too crowded can create a feeling of invasion. Aim for a welcoming, safe place for both mentor and mentee. If possible, the location should lack distractions of computers, mutual acquaintances, patients, and reading or work materials. The mentor should give the mentee his/her attention during the meeting, so an office setting may not be appropriate due to distractions.  The mentor and mentee should avoid speaking or texting on cell phones during the meeting. As the relationship develops, meetings can occur on hikes, walks, or during exercise.


That brings us to listening, one of the most important aspects of the relationship. Two types are predominantly present, including one-way and two-way. One-way (passive) listening occurs with non-verbal feedback from the listener, which includes eye contact, gestures, nodding, and smiling. This can be great for a mentee just needing to vent, requiring a “sounding board”. Two-way (active) listening requires verbal feedback. Both types include questioning, where the mentor attempts to get the mentee to elaborate on information, and paraphrasing, where the mentor speaks back and rephrases to the mentee what was said. This allows both participants to ensure adequate understanding, clarification of ideas, and thought processing.


An agenda or set of goals for every meeting can improve the productivity and further development of the relationship. Planning where, when, and what will be covered is essential. Other keys include allotting an appropriate amount of time, each participant coming prepared, and avoiding surprises. If something needs to be addressed, the mentor or mentee should contact the other before the meeting to ensure the agenda is modified.

The next several components are related and exist along a spectrum.  These include coaching, counseling, guiding, and advising, which are primarily mentor responsibilities.

A. Coaching

The role of coach may be required for mentees who are less experienced in order to gain knowledge or overcome difficulties the mentee may be experiencing. In this role, the mentor should describe the behavior needed, demonstrate why the knowledge or skill is important, explain how to approach the task, act as a role model, observe the mentee, and provide feedback. As you can see, several points are difficult. Observing the mentee and acting as a role model might require working together while on shift.

B. Counseling

Counseling requires trust and confidentiality, as well as a safe environment. Counseling may be needed for work, personal life, or finances. Respect is essential in this interaction. There are many types of counseling, though two will be discussed here. One is a non-directive approach, where the mentor allows the mentee to discover problems and solutions based on his/her own values. This requires active listening on the part of the mentor, who accepts the needs and values of the mentee.  Another approach is more directive, where the mentor assists the mentee by recommending solutions.

C. Guiding

Guiding incorporates assisting the mentee through inner working of a program, rotations, studying, and resources. “Unwritten rules” of the program, institution, and EM as a specialty can be important discussion points, especially critical responsibilities. For junior faculty, a new hospital can present significant challenges with documentation, culture, staff, diagnostic/treatment pathways, pharmacy, labs, and many other components. This is where a mentor or senior physician can assist in discussing these aspects. Inner workings are the “behind the scenes” dynamics or politics, which may not always visible yet can be difficult roadblocks or trouble areas. “Unwritten rules” include special procedures followed, guidelines that may not always be documented, interactions among departments, and policies.

D. Advising

Career advising is a major component of the mentor-mentee relationship. It is also one of the most rewarding aspects. To maximize career advising, several items should be considered:

  1. Determine the mentee’s interests – Ask what activities are interesting or satisfying. What do they enjoy the most, and what do they dislike?
  2. Identify the mentee’s knowledge, skills, and abilities within their interests. Most people are modest and may diminish their description of their own skill. The mentee should seek to evaluate his/her own strengths, weakness, responsibilities, and most significant accomplishments. This will provide insight into what the mentee values, while revealing important attributes. The mentee identifying his/her own skills forces the mentee to closely examine professional and personal interests and accomplishments.
  3. Develop career goals – The mentee should first develop long-term goals and work backwards. Short-term goals should work to accomplish long-term goals. Goals need to be specific, measurable, achievable, relevant, and time-bound (SMART). They also should be time-framed, relevant, realistic, limited in number, and flexible. For more on SMART goal-setting, see https://www.mindtools.com/pages/article/smart-goals.htm.
  4. Target areas that need further development – In order to target development, the mentee and mentor should know the long-term goals and requirements to meet them.
  5. Create a plan – A plan for development includes specific actions needed to achieve desired goals. For this plan, the goals should be listed, followed by the plan with specifics. This plan serves a motivator.
  6. Determine indications of success – The mentee should define their success and list indicators of success.
  7. Evaluate progress – Recurrent meetings can help monitor progress and goals. The plan and even goals can be readjusted at follow-up meetings. Celebrating interim goals are important, as they build the relationship and motivate the mentee and mentor.


Feedback is needed in coaching, as well as other stages in the relationship. Positive feedback can reinforce correct behavior, while constructive feedback seeks to modify or improve behavior. Feedback should be frequent, concise and specific, and direct. Feedback should not be provided as a question, judgmental, or exaggerated. Before providing feedback, try to understand the actions of the mentee, and ensure the setting is optimal.  Asking about the mentee’s thought process can provide valuable insight for the mentor.

Learning from Experience

Sharing prior experiences is important for the mentee and provides insights into how the mentor thinks. Errors and successes should be shared openly yet confidentially, which not only helps the mentee learn, but also strengthens the relationship of the mentor and mentee. To assist the mentee, several steps can be followed:

  1. Ask the mentee for a concrete, detailed description, and inquire about specifics.
  2. Ask about feelings the mentee experienced.
  3. Ask about lessons learned.
  4. Discuss strategies for future scenarios and successes.

Role Modeling

A mentor acts as an example for the mentee, demonstrating professional practices, values, and ethics. This provides an important teaching tool, providing an opportunity to learn. Direct modeling can be difficult in EM because the mentee may not work shifts with the mentor in the ED. However, professionalism, compassion, empathy, and timeliness can be modeled through daily interactions.


This concerns creating and/or looking for new opportunities for the mentee. The mentor’s goal is to provide as much exposure to new opportunities as possible (while limiting risks). These opportunities should challenge and benefit the mentee. However, the mentor should ensure the mentee is set up for success, not failure. This also requires the mentor evaluating the mentee on a regular basis. Once the mentee has accomplished one goal or step on the plan, the next goal should be targeted.

At some point in the relationship (often after several years working together), the mentee may feel they are advancing through association with the mentor, rather than personal merit. The mentor should ensure the mentee’s competence and abilities are visible. The mentor can also connect the mentee to others or guide him/her toward a separate project.


Most mentees in EM will be highly motivated and want to succeed. Mentors may never need to fill the motivator role for their mentee. However, this role may be needed when the mentee feels overwhelmed, has an extremely difficult assignment, or is afraid of failure.  Motivation can take the form of guidance and support in these circumstances. Encouragement involves providing positive feedback during an assignment to help move the mentee towards goals. This feedback can boost the mentee by providing a sense of accomplishment and self-esteem. Motivation also occurs through providing support. Mentor availability during stressful periods can really help the mentee, allowing the two to meet, discuss, and work through challenges or difficulties.

Case 1: At this current stage, the emergency medicine intern needs guidance and coaching from the staff mentor, while continually monitoring her goals and progress. Regular meetings are important. The mentor must continue to support the intern through her years as a resident, while being prepared for challenges associated with residency training.

Case 2: The junior faculty needs guidance and support on the intricacies of the new job and new institution. Career advice is also important to this individual, and a senior physician can provide valuable insight as well as pearls such as mistakes to avoid and what has helped him succeed. Connections are also helpful; the senior staff mentor can assist the junior faculty member in forming important relationships.

Key Points

– Mentoring includes several stages: prescriptive, persuasive, collaborative, and confirmative, though these often overlap and are not always clear cut or linear.

– The mentor and mentee must devote time and energy to the relationship.

Listening skills are essential for the mentor and mentee.

Each meeting is best having an agenda. The meeting should be scheduled in advance with a plan, a location and time, and a set amount of time set aside.

Coaching may be needed for mentees with less experience. Counseling and guidance are important through all stages.

Advising is one of the predominant components of the mentoring relationship. The mentee should identify his/her interests, skills, knowledge, and goals. Targeting areas for development, plan creation, indicators of success, and continual reassessment of progress are vital.

– Mentors should seek to promote the interests of the mentee. Guidance and support may be needed if the mentee feels overwhelmed or experiences difficulty.


References/Further Reading:


  1. Garmel GM. Chapter 4: Mentoring in emergency medicine in Practical Teaching in Emergency Medicine. Second Edition. Edited by Rogers RL, Mattu A, Winters ME, Martinez JP, Mulligan Terrence M. John Wiley & Sons, Ltd. Published 2013.
  2. Yeung M, Nuth J, Stiell IG. Mentoring in emergency medicine: the art and the evidence. Cal J Emerg Med 2010;12(2):143-149.
  3. Garmel GM. Mentoring medical students in academic emergency medicine. Acad Emerg Med 2004;11:1351-57.
  4. Detsky AS. Baerlocher MO. Academic mentoring – how to give it and how to get it. J Am Med Assoc 2007;297(19):2134-36.
  5. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Having the right chemistry: a Qualitative study of mentoring in academic medicine. Acad Med. 2003; 78:328–34.
  6. Advisor, Teacher, Role Model, Friend: On Being a Mentor to Students in Science and Engineering. National Academy of Sciences, National Academy of Engineering, Institute of Medicine. Washington, DC: National Academy Press, 1997.
  7. Clutterbuck D. Everyone Needs a Mentor: Fostering Talent at Work, Ed 3. London: CIPD House, 2001.
  8. Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ. 2002; 325:707–10.
  9. Wright DW, Hedges JR. Mentoring faculty members to the next level. SAEM/AACEM Faculty Development Handbook, Ed 1. Available at: http://www.saem.org/facdev/fac_dev_ handbook/4-2_mentoring_faculty_members_next_level1.htm. Accessed February 2017.
  10. Ramanan RA, Phillips RS, Davis RB, Silen W, Reede JY. Mentoring in medicine: keys to satisfaction. Am J Med. 2002; 112:336–41.
  11. Lewis RJ. Some thoughts regarding gender issues in the mentoring of future academicians. Acad Emerg Med. 2003;10:59-61.
  12. Hamilton GC. SAEM under-represented minority research/mentorship task force: attitudes and opinions of under-represented minority medical students regarding emergency medicine as a potential future career choice. Acad Emerg Med. 2004;11:483-84.

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