letteratura su Prehospital Em. Med.: istruzioni per una lettura corretta

leggere-ai-bambini (1)

Quando leggiamo la letteratura internazionale inerente la nostra branca medica, la prehospital emergency medicine, commettiamo spesso un errore fondamentale: confrontiamo involontariamente mele con pere !

Mele-e-pere_diaporama_550

Cercherò in questo post di spiegare meglio questa mia affermazione.

Il tutto nasce dalle enormi differenze organizzative e culturali presenti tra i vari continenti  e dalla origine, completamente diversa, dei servizi di emergenza territoriale.

Vediamo nel dettaglio:

ITALIA:  il servizio di emergenza territoriale ha avuto uno sviluppo iniziale con l’impiego di medici di derivazione del “Servizio di Continuità Assistenziale” (Guardia Medica). Quindi in Italia abbiamo storicamente la presenza di medici. Negli anni, i vari servizi territoriali si sono dotati di figure mediche con specializzazioni differenti: anestesisti-rianimatori, medici senza una specializzazione precisa, specialisti di area internistica convertiti all’emergenza, medici provenienti dalla Continuità Assistenziale, medici con abilitazione MET (medico emergenza territoriale). Il panorama è ancora variegato sull’intero territorio, al pari delle professionalità espresse. Gli studi provenienti da ricercatori italiani risentono quindi molto della singola realtà organizzativa: in alcuni luoghi l’ecografia preospedaliera è sconosciuta (fondamentale non solo per la gestione del periarresto), mentre in atri distretti non sono ancora in uso farmaci dell’area anestesiologica come i curari o alcuni ipnoinducenti. Quindi prima di trarre conclusioni in merito a ciò che leggiamo in uno studio dobbiamo capire quale sia l’organizzazione locale e le peculiarità dei medici in servizio. Altrimenti si prendono abbagli mostruosi.

EUROPA: se consideriamo il vecchio continente le differenze si fanno più marcate. Nazioni come il Belgio, la Francia, la Spagna e la Germania hanno puntato da molti anni sulla figura del medico sul territorio (più o meno emergentista). Quindi gli studi provenienti da queste realtà mostrano outcome che risentono molto della forte professionalizzazione messa in campo. Dall’altra parte vi è il Regno Unito, la Svezia, la Norvegia in cui invece non è di fatto quasi mai prevista la presenza del medico sui mezzi di soccorso avanzato. In questi casi sono previste figure spesso paramediche con un inferiore grado di conoscenza della medicna d’emergenza. Molti studi sono anglosassoni o svedesi, per questo è fondamentale ricordare come si sono organizzati.

STATI UNITI: è sicuramente la fonte più prolifica di articoli inerenti la prehospital emergency medicine. Assieme all’Australia condividono l’organizzazione più distante da quella europea tradizionale (eccetto UK): il soccorso di emergenza è basato sulla figura degli EMT (Emergency Medical Technician). Come sappiamo si tratta di paramedici (quindi né medici né infermieri) con una preparazione tecnica basata sulle linee guida di programmi formativi standardizzati come AMLS, PHTLS, ALS. Ovviamente il loro background professionale non è paragonabile a quello generalmente espresso dalle figure mediche ed infermieristiche europee.

ASIA ed EST del MONDO: In Cina il servizio territoriale è spesso affidato a paramedici ma in alcuni casi il medico ospedaliero sale sul mezzo avanzato e arriva dal paziente. Inoltre, in caso di maxi-emergenza è l’esercito che interviene: il soccorso è gestito da medici. In molti paesi dell’ex blocco sovietico abbiamo servizi territoriali con il medico. In Giappone non è invece previsto di norma la figura medica (a parte alcune realtà).

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Quindi, a livello mondiale, l’organizzazione dei servizi di emergenza territoriali sono completamente diversi e poggiano su basi culturali e tecniche eterogenee.

Da ciò deriva un enorme problema interpretativo: come possono essere utilizzati studi che provengono da organizzazioni così differenti ?

Un errore classico, ad esempio, è stata l’erronea interpretazione degli studi sull’efficacia dell’intubazione oro-trachaeale in prehospital: gli studi anglosassoni da sempre hanno fornito dati pessimi riferiti agli outcome primari, mentre gli studi europei producevano dati eccellenti. La differenza era evidentemente determinata da chi effettuava la manovra. Nelle prossime settimane posteremo un riassunto di questi studi sottolineando le evidenti differenze di outcome.

Ricordiamo inoltre le diverse strategie di approccio al paziente: scoop and run (anglosassone) vs stay and play (europeo). Anche qui i dati sono fortemente contrastanti, in relazione a chi ha svolto gli studi (si vedano gol outcome relativi alla gestione del trauma).

Per concludere, consigliamo quindi sempre di controllare la provenienza di uno studio di prehospital emergency medicine, per non commettere errori interpretativi ma soprattutto per non effettuare considerazioni organizzative che risulterebbero erronee per le proprie realtà operative. Un altro aspetto fondamentale che emerge dall’analisi di letteratura sta nella povertà di studi provenienti da nazioni fortemente medicalizzate. Per questo tutti noi dovremmo sentirci spronati a produrre trials (ed in genere lavori) che supportino il nostro operato. Un caso molto interessante è rappresentato dal lavoro portoghese della Gomes, che ha decretato, una volta per tutte, come i servizi di emergenza che impiegano unità operative con medico ed infermierie riducano la mortalità rispetto a organizzazioni con solo infermiere o con soli volontari (su pazienti traumatizzati).

Nel nostro blog non mancheremo mai di segnalare la provenienza dello studio, soprattutto in relazione agli scopi dimostrativi degli autori !


Archiviato in:Elisoccorso, Emergenze Cardiologiche, Emergenze Mediche Subacquee, Emergenze Neurologiche, Emergenze Respiratorie, Maxiemergenza Preospedaliera, Medicina d'Alta Quota, Prehospital Strategy, Search and Rescue, terapia del dolore, Trauma Tagged: ACLS, ACR, ALS, europa, germania, hems, itaia, letteratura, outcome, rianimazione, scoop, scoop and run, spagna, stay, stay and play, strategia, studio, svezia, terapia, trauma, trial, trials, UK, USA

The LITFL Review 146

LITFL review

The LITFL Review is 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 chuck of FOAM.

Welcome to the 146th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerBrilliant new series from Academic Life in Emergency Medicine highlights how successful people in EM work smarter. Posts from Michelle Lin, Victoria Brazil and Esther Choo. [AS] Want a simple, awesome and comprehensive guideline?…Check out these Guidelines for Paediatric Concussion [KG]

The Best of #FOAMed Emergency Medicine

  • Computers can’t be trusted to do simple calculations . . . at least not when it comes to the QTc duration. Stephen Smith discusses in a case of syncope and bradycardia. [AS]
  • With changeover of junior doctor’s looming in the UK, the EmergencyPedia team set out 10 fundamentals of how to impress in the Emergency Department. [SL]
  • Wonder how accurate your respiratory diagnoses are in the ED? The St.Emlyns team discuss potential to improve our practice following a recent publication on point of care ultrasound for the breathless patient. [SL]
  • A pharmaceutical company (Boehringer Ingelheim) suppressed data? Inconceivable! If you’ve fallen behind on the dabigitran controversy, Ryan Radecki gives a short commentary on the situation. [AS]
  • New LBBB = STEMI? Not always. New LBBB with > 5 mm discordant ST elevation = STEMI? Nope. Great case from Stephen Smith highlighting the fact that ST segment elevation increases with tachycardia and the importance of STE-S wave ratio. [AS]

The Best of #FOAMcc Critical Care

  • How should we care for the sick and trying to die pregnant patient? Haney Mallemat discusses the Critical Pregnant Patient on the All NYC EM Podcast. [AS]
  • More greatness from SMACC Gold: Scott Weingart weighs talks on Sepsis in New York:  Our first 15,000 patients, while Mark Wilson talks on Monroe Kellie 2.0. [SO]
  • Interested in ICU physiology, particularly heart-lung interactions? Jon-Emile Kenny from Vancouver has an excellent set of animated lectures at www.heart-lung.org. Check them out! [SO]
  • Trans-oesophageal echo. It’s complicated, bulky, and outside the remit of point-of-care use for resuscitationists. Or is it? Matt and Mike from the Ultrasound Podcast present a lecture on POC TEE/TOE by Rob Arntfeld: Part 1 & Part 2 [SO]

#FOAMPed Paediatrics

  • Sean Fox at PED EM Morsels reviews delayed diagnosis of foreign bodies. It might be just a cough, but consider asking about that peanut they choked on six months ago…. [TRD]
  • Don’t Forget the Bubbles reviews a recent paper on ketamine dosing in obese adolescents – are we giving them too much? [TRD]
  • Is loss of consciousness useful in determining which kids with minor head trauma need a head CT? Rory Spiegel delves into the PECARN data and discusses its limitations. [AS]
  • Kids are just little adults. At least when it comes to the first hour of sepsis management, Simon Carley argues to think of kids as little adults to prevent the paralysis induced fear that EM physicians who rarely treat kids can feel. [AS]

The Best of #FOAMTox Toxicology

  • Poisoned patients…….the next group of ED patients to benefit from the bedside US?  Dr Leon Gussow discusses the use of POCUS for the poisoned.  [CC]

News from the Fast Lane

  • Michelle is back with her masterful writing skills with a look at Nothing New Under the Sun….Will have you thinking and questioning your own small world! [KG]

Reference Sources and Reading List

 

The post The LITFL Review 146 appeared first on LITFL.

Medicación para los vómitos


Fuente: gettyimages
Patología frecuente en cualquier punto de consulta en la mayoría de los casos autolimitada y sin consecuencias. Sin embargo, al menos en mi experiencia, es en los puntos de atención urgente tanto en los PAC como en el hospital donde con más frecuencia usamos los antieméticos. Más que en las consultas de Atención Primaria. Probablemente sea debido a que las expectativas de los pacientes en cualquiera de las urgencias hacen mucha presión sobre nuestra decisión.
Por eso me ha llamado la atención este artículo reciente del que solo he leído el resumen pero con resultados interesantes, utilizan el ondansetron, la metoclopramida y el placebo y aunque los resultados tienden a ser mejores con los tratamientos activos, no hay diferencias estadísticamente significativas entre ellos. Esta es la traducción del resumen:
Las reducciones en la severidad de la náusea de esta población población fueron similares para 4 mg por vía intravenosa de ondansetrón, 20 mg de metoclopramida intravenosa y el placebo. Hubo una tendencia hacia una mayor reducción en las calificaciones de la EVA y a  un requerimiento menor de medicación de rescate en los grupos de fármacos antieméticos, pero la diferencias con el grupo de placebo no alcanzó significación. La mayoría de los pacientes en todos los grupos se mostraron satisfechos con el tratamiento.

Como tantas otras veces...menos puede ser más.

 

Medicación para los vómitos


Fuente: gettyimages
Patología frecuente en cualquier punto de consulta en la mayoría de los casos autolimitada y sin consecuencias. Sin embargo, al menos en mi experiencia, es en los puntos de atención urgente tanto en los PAC como en el hospital donde con más frecuencia usamos los antieméticos. Más que en las consultas de Atención Primaria. Probablemente sea debido a que las expectativas de los pacientes en cualquiera de las urgencias hacen mucha presión sobre nuestra decisión.
Por eso me ha llamado la atención este artículo reciente del que solo he leído el resumen pero con resultados interesantes, utilizan el ondansetron, la metoclopramida y el placebo y aunque los resultados tienden a ser mejores con los tratamientos activos, no hay diferencias estadísticamente significativas entre ellos. Esta es la traducción del resumen:
Las reducciones en la severidad de la náusea de esta población población fueron similares para 4 mg por vía intravenosa de ondansetrón, 20 mg de metoclopramida intravenosa y el placebo. Hubo una tendencia hacia una mayor reducción en las calificaciones de la EVA y a  un requerimiento menor de medicación de rescate en los grupos de fármacos antieméticos, pero la diferencias con el grupo de placebo no alcanzó significación. La mayoría de los pacientes en todos los grupos se mostraron satisfechos con el tratamiento.

Como tantas otras veces...menos puede ser más.

 

A few tips to help the new-graduate nurse flourish.

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One question I get asked a lot is for tips to help out new-graduate nurses or nurses just starting on a new ward. It can be a very stressful time.
Here is a (by no means exhaustive) scratch-list of tips to help the new nurse not just survive, but flourish.
As usual,  your own tips are welcome.

To do list.

Before starting:

Acquire any personal clinical equipment you might need. See below.

Contact your new unit manager to confirm starting date, initial roster etc. Ask if there is an unit specific information or educational materials that is available before you start.
Ask if you can have a quick 5min walk-through orientation before you start. This is very helpful just to get the ‘lay of the land’ and remove some of the fear of the unknown before your first shift.

First day:

Remember to breathe. Remember to smile.

You will be leaving an impression over your first few days. Rightly or wrongly you should take time with personal grooming and dress so as to give a presentation of professionalism. Personally, I really enjoy people who express a little individuality in their professional persona. But many others do not. Best to remove excessive jewellery piercings etc. At least until you have settled in to the unit.

Try to remember the names of key staff that you are introduced to (if you are anything like me you will fail dismally at this, so write them down in your notebook at earliest opportunity).

Introduce yourself to everybody you possibly can on your unit. From clinical educator to cleaner. You will feel silly doing this. But do it anyway.

Listen. Listen. Listen.

First week:

If you have been given any orientation materials for your new unit, try and read it all through at least once during the first week.

Take note of staff that are particularly supportive or helpful.
Now a few words about this:  Most wards will have a few staff that are NOT going to be particularly supportive or receptive to you. And some wards will have a few staff that are curmudgeonly, toxic, demanding and/or outright bullying.
As you interact with staff and begin working your way through the shifts it will not take long to figure it all out. But remember ,sometimes even the best role models will have off days, and sometimes they will be struggling with their own workloads and clinical issues.

Pace yourself. If you are feeling overwhelmed, take a moment to step back and look at what needs to be done. Always ask yourself: “what is THE next most important thing that I need to do?”.
Try not to multi-task too much (though this is easier said than done) or get distracted by low priority interruptions. Do one thing at a time and do it well.

Think about how you are thinking (this is known as meta-cognition) and if you are struggling THE most important thing to do is ask for help.
You may sometimes feel that you spend the whole shift asking questions and asking for help, but let me say that nurses who do this ALWAYS go on to perform more confidently and are looked upon more highly by colleagues than those who try to struggle-on not admitting their problems to others, or themselves.

Remember the basics. Nurses are seldom remembered for their knowledge of the thermodynamics of blood gas analysis, or their ability to recall every hospital policy and procedure verbatim. No, the best nurses are always remembered for their ability to provide consistent, quality basic (essential) nursing care.
Concentrate on this with your patients.

First month.

At some stage during the first month you may hit THE WALL.
Splat!
You may feel completely overwhelmed, underprepared, exhausted and useless. You are particularly likely to encounter the wall in high acuity areas but it can happen anywhere.
If you beginning to feel this way you need to talk to trusted senior staff and/or your unit manager.

After 28 years nursing I can assure you that nurses that really struggle at the beginning often become the best clinical nurses I have worked with.

By the end of your first month you should ask for a meeting with your manager or educator to discuss you progress and examine your needs and goals over the next few months.

Attitude.

You may move onto the ward busting at the seams with big ideas to improve care delivery, and a somewhat, er…. assertive impatience to make your way to positions of leadership and influence .
Conversely, you may feel totally overwhelmed and under-prepared to go out into the clinical world.
More than likely you will feel somewhere in the left-of-middle area in this spectrum.

The attitude that we are looking for in new graduate nurses is one of being a safe practitioner with clinical confidence, circumscribed by a beginners-mind and strong meta-cognative & self-reflective abilities.

You have now successfully completed your university studies. You have been found competent to practice as a registered nurse. You have learned the skills. You have accrued the knowledge. You have come a long way.

As I always say, there is only a very small percentage of people in our community who have the right parts knowledge, compassion, resilience and tenacity to do what it is you are now dedicating a fair chunk of your life to.
You are already awesome and you should acknowledge this and draw a certain confidence from it (In fact it will probably be many years yet before you really understand just how awesome you are).

In short, it is time. You are ready to begin your path.

But it will certainly be different to anything you have experienced before. No matter how much clinical time you have accrued. The depth of responsibility, the multitude of demands, and the palette of emotions in which you will be immersed once you take your first patient load is…….well it is exactly 4,354 end-to-end textbooks away from your experience thus far.

No matter, you will be amongst friends. And despite what you have heard about nurses “eating their young” there will be a large number of nurses willing to support and assist you.

In Zen, there is an important concept called Shoshin which can be translated as Beginner’s Mind.
Shunryu Suzuki, a famous Zen teacher once said:

In the beginner’s mind there are many possibilities, in the expert’s mind there are few.

In nursing, a beginners mind (or novice mind) might relate to having an attitude of openness, eagerness, flexibility and lack of preconceptions when engaging in patient care. Every nurse should have a beginners mind. Especially the experts.

One of the things I enjoy most about working with new graduate nurses is this open-minded, enthusiastic, flourishing that the best of them always seem to exude.

So. Small steps. Take time to dip into this profession. Percolate. Find the area that best stimulates your flourishing. Value the lessons that you will learn from more experienced staff. Seek out the good teachers, exemplary role models, and inspiring mentors. You will find them.

Equipment.

Shoes. Essentially (in order of importance) you will want shoes that are comfortable, provide protective support, are impermeable to fluids, have a non-slip sole and look professional.
Here is a whole page of nurses discussing their preferred brand of nursing shoes.

Stethoscope. This is NOT an ornament. It is a weapon against clinical calamity.
It is wise to invest in a decent stethoscope. However a word of advice, don’t buy one of those top-of-the-range digital super-stethoscopes (unless you are hearing impaired) because a) it tends to do the opposite of impress, and b) you will probably loose it, or break it way too quickly.

Notebook. Essential bit of equipment for capturing important information (see how I use my own notebook here), jotting down extension numbers or (if you are anything like me) the names of important staff that you will otherwise forget). Any cheap pocket sized notebook will do. But I like these Field Notes.

Pouch. Infection control issues aside, utility pouches seem to have become pretty popular with nurses these days. Around our own hospital the pick-pocket brand seems to be one of the most popular. They are cheep, lightweight, come with their own belt and easily carry pens, notebook, tape and even mobile phones.
They also sit quite flat & snug against the body so you don’t look like you are about to climb up an electricity pole and disconnect something important.
There are plenty of other varieties available.

Neuro-torch. Most nurses will find a neuro-torch essential as part of their clinical assessment kit. Some wards will provide them as ward stock. If not, you can purchase task specific neuro-torches (many include a chart of pupil sizes printed on their side) online.
Any cheap small pocket torch will suffice as long as its beam is not too bright.
Read: how to become a neuro-torch Jedi.

Pen. You will lose it.


Reference: Featured image via Nat