Sunday, May 29, 2016

Patient Satisfaction

Common Sense - AAEM Member Magazine
Author: Victoria Weston, MD
AAEM/RSA Immediate Past President
Originally Published: Common Sense March/April 2016

Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.

I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.

Sunday, May 22, 2016

Electrical Storm: Don’t Just “Push Another Milligram of Epi”

This post was peer reviewed.
Click to learn more.

Author: Khalid M Miri, OMSIV
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

"Are you ready to call it?" "Not yet, let’s push one more of epi." Sound familiar? Despite doing proper CPR, defibrillating, and pushing all the ACLS meds, you know deep down that after the first few rounds of chest compressions, your cardiac arrest patient has a tiny chance of surviving to discharge in good neurological condition. You have seen too many codes that go on too long and all you know to do is keep pushing epinephrine and hope that your patient is that one rare case that will achieve sustained ROSC. Have you ever wished you had another option, something that might work when epinephrine and amiodarone do not? Well, an additional option may exist. During a specific condition — refractory ventricular fibrillation — research shows that using a beta blocker can have a better chance of bringing that patient out of their dysrhythmia than when using epinephrine and antidysrhythmics alone.

Cardiac electrical storm (ES) is often defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. It is a dangerous arrhythmia that leads to refractory VF and will kill most of its victims despite treatment with the current ACLS recommendations of epinephrine, antidysrhythmics, CPR, and defibrillation.[1]

Sunday, May 15, 2016

Which Patients Should Have Blood Cultures Collected?

Author: Linda Sanders, MD PGY3
Temple University Hospital
Originally Published: Modern Resident April/May 2016

Patients with bacteremia have a mortality between 30 and 50%, thus obtaining culture data on these sick patients is critical.[1] On the other hand, in the immunocompetent, non-septic patient, blood culture data rarely changes management, has a low yield, with a high rate of contamination and increases cost. False positive blood cultures increase length of stay by four to five days.[2] In order to provide high quality, cost-effective care, emergency physicians need to know which patients benefit from blood cultures being collected.

Blood Cultures in Cellulitis, Pyelonephritis and Pneumonia

The yield of blood cultures in patients with cellulitis is only two percent.[3,4] Meanwhile, the rates of contamination are equal to the rate of true positives and results rarely change antibiotic choice.[3,4] This is true for complicated and uncomplicated cellulitis, ICU patients excluded.

Sunday, May 8, 2016

Digoxin Toxicity: Myths, Truths and Management

This post was peer reviewed.
Click to learn more.
Author: Andrew V. Bokarius, MD
Emergency Medicine Resident
University of Chicago
AAEM/RSA Publication Committee Member

The Case:
A 68-year-old male with a history of heart failure presents with weakness, confusion, and visual disturbances including yellow/green halos and scotomas. Digoxin is on the list of current medications. Vitals are notable for bradycardia with a HR of 55. The patient is awake but confused.

The Clinical Decision-Making:
While your differential diagnosis may include calcium channel toxicity, beta blocker toxicity, sick sinus syndrome, clonidine toxicity, organophosphate poisoning, and other potential diagnoses, digoxin toxicity should be at the top of the list.

You quickly recall how digoxin works: it inhibits the Na/K ATPase, causing intracellular sodium levels to rise. Sodium is then exchanged for calcium via a Na/Ca transporter. The intracellular calcium concentration is thus increased, thereby increasing contractility. Furthermore, digoxin also may increase vagal tone and can lead to bradyarrhythmias.

Sunday, May 1, 2016

Wilderness Medicine: Special Considerations for Submersion Injuries

Image Credit: Flickr
Author: Mike Wilk, MS4
Loyola University Chicago Stritch School of Medicine
Originally Published: Modern Resident February/March 2016

Drowning still remains a leading cause of accidental death in the United States, particularly for young children.[1] In the past, many terms were developed in reference to subtypes of drowning such as near drowning, dry and wet drowning and shallow water blackout. However, recent guidelines have been simplified and now only categorize a drowning as fatal or non-fatal.[2] Drowning occurs after an initial period of panic and breath holding, which eventually leads to reflex inspiration as water enters the respiratory tract causing widespread hypoxia.

Based on previous animal model studies, it was once thought that there were physiological differences in saltwater versus freshwater submersion injuries that could thus require differing treatments. For example, it was thought that since freshwater submersion aspiration contents are hypotonic, it would result in intravascular fluid overload leading to hypotonic serum levels. Contrasting saltwater submersions, aspiration was thought to be hypertonic in nature, thus leading to massive pulmonary edema and hypertonic serum levels. In reality, nearly all survivors simply do not aspirate enough fluid that lead to clinically relevant changes.[3]