Research and Reviews in the Fastlane 183

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Research and Reviews in the Fastlane

Welcome to the  183rd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains  5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Justin Morgenstern and Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Critical Care
R&R Hall of Famer - You simply MUST READ this!
Seymour CW, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 2017. PMID: 28528569.

  • The authors performed a retrospective study examining the time to treatment of septic patients and mortality. They used data required to be collected and reported by the state to determine the relationship between mortality and time to completion of a sepsis bundle, fluid bolus administration, and antibiotic administration. Significantly, with almost 50,000 patients included in their analysis, they found an association between timing of both completion of a 3-hour bundle and broad spectrum antibiotic administration with mortality. In essence, early identification and treatment for these patients DOES matter.
  • Recommended by: Jeremy Fried

The Best of the Rest

AirwayR&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practice Cox R et al. Yankauer Suction Catheters with “Safety” Vent Holes May Impair Safety in Emergent Airway Management. Am J Emerg Med 2017. PMID: 28457763

  • This is a simple study demonstrating the importance of uniformity and simplicity in airway management. When residents were challenged with a suction device requiring occlusion of a vent hole that required occlusion for function, 76% failed to occlude the hole immediately and 60% didn’t occlude the hole after 20 seconds. Part of the issue may arise from the fact that different catheters were stocked at the different clinical settings the residents worked in. The answer, eliminate the vent hole or, at least, maintain uniformity across clinical settings. Of course, this information does nothing to remedy the poor quality of suction the Yankuer provides in the first place.
  • Recommended by: Anand Swaminathan

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceSchriger DL et al. Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and are Seldom Superior. Ann Emerg Med 2017. PMID: 28238497

  • Every Emergency Provider loves a good decision instrument but are they better than the physician judgement they are attempting to replace? This brilliant study shows that most clinical decision tool studies fail to ask the most important question – is this better than what we’re already doing?
  • Recommended by: Anand Swaminathan

Emergency MedicineR&R Game Changer? Might change your clinical practice Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. AJEM 2017. PMID: 28320545

  • In this small, retrospective study, 5mg IM Haldol decreased rates of admission and amounts of opioids administered in patients with diabetic gastroparesis. Haldol could be a potential addition to the armamentarium of treatment in this difficult to treat disease process.
  • Recommended by: Salim R. Rezaie
  • Read more: Diabetic Gastroparesis Needs HUGS (R.E.B.E.L. EM)

ToxicologyR&R Game Changer? Might change your clinical practiceNelson CJ et al. Morbidity and mortality associated with medications used in the treatment of depression: an analysis of cases reported to US poison control centers 2010-2014. Am J Psychiatry 2017. PMID: 28135844

  • Use of TCAs and MAOIs for treatment of depression has largely given way to the more popular and safer SSRIs. Overdose of SSRIs are comparatively well tolerated and managed relatively easily with good supportive care. With the emergence of the newer antidepressants, particularly the DNRIs (bupropion) and SNRIs (venlafaxine, duloxitine), more serious and even fatal toxicities are not uncommon. Though causality cannot be inferred due to limitations in poison center data, this article highlights the increased attention and caution EM providers should give to overdoses of newer antidepressant medications.
  • Recommended by: Meghan Spyres

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: May 25, 2017 @ 9:55 am

Research and Reviews in the Fastlane 183
Jeremy Fried

How to be EPIC

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Let it never be said that we resist change. We, the consultants in my ED, have been reinvented. Previously our title was Duty Officer, which had a pleasantly communist, scratchy grey-overalled sound to it, but now we are the EPIC. An imperious title, in my opinion.

This stands for Emergency Physician In Charge.

Here’s where the duplicity begins. I’m hardly in charge of my own brain, so feigning tight command of the beast of the Emergency Department is a bit of a stretch.

But still, I turn up for shifts. At least I dress appropriately. I wear scrubs which make me look like a scrawny Police Officer but without the fun stuff hanging from my belt. I carry THE phone. Yes, the one that has the broken ice-cream truck ring tone that peals out horribly during the depths of sombre conversations; the phone that conveys endless information bytes about patients who may, or may not, pass through our doors, or otherwise random requests or facts upon which I am allegedly supposed to act. With this, though, I am firmly in charge. I don’t answer it. That’s the limit of my in-chargeness, I think.

The days vary, like all good days in the vortex of Mount Doom. Let’s take one.

I start it by thinking about coffee, which is then rudely interrupted by waves of patient chaos. Busloads of them and their shaky pathology. By nine I am wondering whether I am coming down with some rare form of illness, perhaps vasculitis, or takotsubo cardiomyopathy, but it turns out I just want coffee.

I am supposed to be at, or possibly in, a huddle. I don’t know what a huddle is. I find out it is a meeting with people who are pivotal in managing patient flow, who will tell me exactly the number of beds we don’t have. Some people will get told off. I don’t get told off, because I don’t know such meetings are being held. And I don’t answer my phone.

Next the bat phone goes off. This is good, because this is what we train for. The registrars go head to head, fighting to answer the phone, because whoever answers it gets to run the code. A registrar is injured in the elbowing melee. They need to go lie down in resus. As I am puerile I announce the incoming code over the tannoy like an airhostess.

No one is amused.

The code is a patient with crashing sepsis. Because I am so epic, I am not allowed to touch the patient. I look longingly at the patient’s veins, and imagine slipping a central line into the subclavian to a round of applause, using only landmarks and the fairy dust of a clinician who has been around for so long that they have a sixth sense where these structures are, like a Baggins in the Shire. This does not happen. The registrar slides the CVC in with exquisite skill, brandishing the ultrasound probe like nun-chucks.

He does not need applause.

By now my need for coffee has become sentient, and is talking loudly in my head and causing hallucinations. I decide I will have to drink the hospital brew. Sadly, our hospital cafeteria has insisted that the coffees need to be reproducible, so they have replaced the baristas with an automated grinder. I am not joking here. Something about benchmarks and KPIs. For coffee. At this point it doesn’t matter. I am prepared to drink anything, and don’t judge the drink for its dystopia.

I am ready, then, for the next patient (keeping in mind that I am so epic I know exactly what’s going on with every single one of the rest of the 45 patients in the Emergency Department – what their plans, vital signs, and backstories are, as well as the reasons for them breaching some weird militarily-enforced time-target. How do I know? Well that is the secret of being epic).

The next patient is a trauma, a rather bloody and moderately deconstructed victim of speed and inattention. This time, I get to watch a registrar running the trauma, who is doing something called a work-place based assessment. This seems to be a mechanism designed purely so someone as garrulous as me is forced to shut their mouth and watch a trainee perform. In this way I can constructively educate and assess the registrar at the same time. My hands are so itchy to get in there and be involved in the intimacy of patient care that they could be weeping in my pockets. The registrar does a fabulous job, and I have only interrupted her about eighteen times. The patient does fine.

I’ve had enough. I want to see a patient myself.

I sneak into a cubicle and stealthily close the curtain, where I begin to take a history from a fabulous old man who has been waiting (patiently) for 3 hours to be seen, who is telling me where he fought in the war. But now I am hauled out to a meeting, because I wasn’t smart enough not to answer the phone. I am in trouble. They ask me why it’s taken so long to see the little man who fought in the war. I would like to make a witty joke about the irony of this, but the people with clipboards don’t look in the mood for a joke.

Basically the day continues like this. Sometime after lunch I feel I would very much like a nap. I look plaintively at the distressed relative’s room, and wonder if I could jigger the lock so I could have forty winks, but the phone rings again.

I am surprised by the variety of requests that come through on the EPIC phone. Mostly my job is to try and construct an answer without getting too cross. Often the answer will end up being of little use to anyone, but I have learnt to phrase things just right so nobody knows that until well after they’ve rung off. A resident calls in sick. This is bad, because it now leaves the number of residents to staff the evening shift as a negative integer. We are suffering from junior staff cachexia at the moment. Everything has been downgraded. For political reasons our hospital has been repurposed and rebranded. Where we used to be the state’s top dog, we are now the punchy little sibling.

Things may well change, and it is likely they will. Working here for decades has made it clear that the health ride consists of the dizzy peaks of the rollercoaster interspersed with the gut dropping lows, complete with arms flailing and eyes squeezed shut (or that could just be me). I am immensely proud to work amongst a team that has hung in there, undistracted for the most part by the flighty decisions made by health bureaucrats. The professionalism and commitment of my brethren to patient care has never wavered.

And then, just like that, the day ends. My shift trying to keep the lid on the bubbling pot of entropy is done. I hand over the phone. Someone else gets the chance to be EPIC. And I’m sure they will be.

EPIC Emergency Physician in Charge

How to be EPIC
Michelle Johnston

LITFL Review 283

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 283rd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

An incredible and eye opening review of his visit to meet the team at Mitchell’s Plains in South Africa and the stark reality of treating incredibly sick folks in sometimes limited setting really hitting hard for Simon Carley. [CC]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMus Ultrasound

The Best of #FOAMpeds Pediatrics

  • Thom O’Neill reviews a recent paper on the challenges faced by LGBTQ+ paeds patients. Real soul searching and enlightening stuff.  [CC]

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

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Last update: May 22, 2017 @ 4:24 pm

LITFL Review 283
Anand Swaminathan