Physician Advocacy: Disability Coverage for the EP

Photo Credit: Flickr - Zeevveez

Author: Linda Sanders, MD
Temple University Hospital
Originally Published: Modern Resident February-March 2016

As a new generation of residents prepares to enter private and academic practice as attending emergency physicians, most intend to practice emergency medicine for the next 30 years, maybe more. But in an environment that demands that we have fine motor skills, quick decision making abilities, fast communication and the ability to practice at least eight hours a day, a physical or mental ailment can make one incapable of EM practice. The incidence of disability among practicing physicians is around 2-10%.[2]

Use of Mechanical CPR Devices has Increased 1,511% - What You Need to Know

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Author: Jake Toy, OMS II
Western University of Health Sciences
College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee Member

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Introduction
There are an estimated 424,000 out of hospital cardiac arrests (OHCA) among Americans annually.[1] Survival rates for OHCA are low, ranging from 10.6% to 31.4%.[2] External defibrillation and CPR represent the first line treatments for OHCA. The American Heart Association (AHA) defines high-quality CPR as 100-120 compressions per minute (CPM) at a depth of 2 inches on the average adult. Allowance of full recoil, minimization of compression interruptions, and avoidance of excessive ventilation are also important (Figure 1).[3] 

Figure 1. 2015 American Heart Association Adult CPR Guidelines (Source – American Heart Association[2])

Tox Talks: Lithium Toxicity

Author: Kaitlin Fries, DO PGY1
Doctors Hospital
Originally Published: Modern Resident, December 2015/ January 2016

Lithium is often a first line treatment for bipolar disorder and major depressive disorder, and is commonly present on many emergency department patients’ medication lists. Studies have shown that as many as 75-90% of patients taking lithium long-term develop toxicity at some point throughout their treatment.[5] This is primarily due to the fact that lithium has a very narrow therapeutic index. In 2008, the American Association of Poison Control Centers received over 6,000 reports of potential lithium toxicities and four reported deaths.[5] While lithium toxicity is not as commonly seen as some other toxidromes in the emergency department, it is still very relevant to daily practice.

Journal Club: Steroids for Everything?

Author: Linda Sanders, MD PGY3
Temple University Hospital
Originally Published: Modern Resident, December 2015/ January 2016

Back Pain
A randomized controlled trial (RCT) in which 269 patients with lumbar radiculopathy on MRI and low back pain were given a 15-day course of prednisone versus placebo demonstrated an improved disability score at three weeks after receiving steroids.[3] By comparison, a RCT of 67 patients presenting to the ED with musculoskeletal pain from a twisting or bending injury not thought to be radicular in nature demonstrated no benefit in pain or disability with prednisone at one week.[2] Thus, steroids may benefit patients with lumbar radiculopathy but have no demonstrated benefit in those with musculoskeletal back pain.

Pharyngitis
A Cochrane review of eight RCTs comparing steroids to placebo demonstrated that patients given oral or intramuscular steroids for pharyngitis were three times more likely to have resolution of pain within 24 hours with a number needed to treat of 3.7.[4] Most trials used a single dose of dexamethasone and all eight studies gave both groups antibiotics. Thus there is no data demonstrating the benefit of steroids without antibiotics.

Drowning in your own Blood: Managing Massive Hemoptysis

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Author: Jonathan Morgan, MSIV Lake Erie College of Osteopathic Medicine-Bradenton

Case:
EMS calls; they are 5 minutes out
with a 50-year-old female patient in cardiac arrest with massive airway bleeding. She began coughing up blood and collapsed several minutes prior to EMS arrival. She is currently intubated with a 7.0 ETT, 3 doses of epinephrine have been administered, and CPR is ongoing; she has been alternating between

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PEA and asystole. Family reported a recent diagnosis of lung cancer.

What defines massive hemoptysis?
There is no consensus on the definition of “massive.” Many sources use a definition of 600cc of expectorated blood per hour, but proposed cutoffs run between 200 and 1000 mL/hr. [1] However, estimating blood volumes can be difficult and it may only take 100-400mL of blood in the airway to cause impaired gas exchange.[1,2] Because of this, some proposals call for inclusion of other clinical data including evidence of impaired gas exchange or hemodynamic derangements to define “massive.”[3]

What is the likely etiology of this patient’s cardiovascular collapse? 
Asphyxiation rather than exsanguination is the most likely cause of cardiovascular collapse in massive hemoptysis.[4] 90% of cases of massive hemoptysis are caused by bleeding in the bronchial circulation, which is exposed to systemic pressures; bleeding in the low pressure pulmonary circulation accounts for only 5% of cases.[2]