How to deal with bad outcomes

[Rekt]

Despite rusteds giggle at this comment, I absolutely take it into account. The 3rd trimester pregnant lady who was sent in with a positive dimer because some idiot NP ordered it for the chest pain that she had with coughing? Didn't scan. Yeah, dimer is positive but I'm not in good conscience going to cta this woman because of a positive dimer that I never would have ordered.

I documented the hell out of that visit and spent a solid 30 min in the room with the patient but we were all very much on the same page at the end of it.

Also, to address birdstrike's comment, I definitely use decision rules. PECARN springs to mind as something I will always reach for. If the argument is "you should be ordering a test" in those cases, I think we have a fundamentally different way of practicing medicine.

Over age 50? Radiation concerns vanish entirely.

I also disagree. Decision rules exist to reduce unnecessary testing and admissions. 1-2% miss rate (aka 98% accuracy) should be more than completely acceptable. There's more patient harm with getting closer to 100% than a target of 98%.

Obvious case-by-case, but I don't hesitate at all to scan a pregnant female. All recent literature supports that the actual radiation dose is incredibly small and non-harmful.

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[futureapppsy2]

I also disagree. Decision rules exist to reduce unnecessary testing and admissions. 1-2% miss rate (aka 98% accuracy) should be more than completely acceptable. There's more patient harm with getting closer to 100% than a target of 98%.

Obvious case-by-case, but I don't hesitate at all to scan a pregnant female. All recent literature supports that the actual radiation dose is incredibly small and non-harmful.

Do you have citations on that last point by chance? It's been a few years since I looked into it, but I recall some studies that showed a decent link between pediatric CT scans and elevated ~10-15 year cancer risk, after controlling for a lot of potential confounds.

 

[TooMuchResearch]

Does/how does the risk of radiation exposure from CT scans enter into your decision making WRT ordering CT scans or not?

Not.

 

[RustedFox]

Despite rusteds giggle at this comment, I absolutely take it into account. The 3rd trimester pregnant lady who was sent in with a positive dimer because some idiot NP ordered it for the chest pain that she had with coughing? Didn't scan. Yeah, dimer is positive but I'm not in good conscience going to cta this woman because of a positive dimer that I never would have ordered.

I documented the hell out of that visit and spent a solid 30 min in the room with the patient but we were all very much on the same page at the end of it.

Also, to address birdstrike's comment, I definitely use decision rules. PECARN springs to mind as something I will always reach for. If the argument is "you should be ordering a test" in those cases, I think we have a fundamentally different way of practicing medicine.

Over age 50? Radiation concerns vanish entirely.

Excellent points. Let me address them one by one.

1. 3rd trimester pregnant lady; yeah - If you order the dimer, there's a whole "dimer values adjusted for pregnancy" table that I used to have on hand but no longer do and now I need to find it again (thanks, bro). But yeah; if the presentation is inconsistent with PE, then un-click the box to order the dimer.

2. PECARN is a bit different of a bird altogether, I'll argue. That's a peds brain CT. Hard left turn at Albuquerque.

3. Over age 50 = radiation concerns vanish entirely. Agree in full - and I'll take this opportunity to remind you that I work in the United States Capital of Turbo Old People where my average patient age is 76.

 

[Janders]

Old people get CTs
Sick people get CTs
Young / healthy people get my expertise, decision rules, shared decision making, and often no CTs.

The large swath of grey zone in the middle is where the magic happens

Aside from guiding you, and providing potential medico-legal protection when appropriately applied, in the new coding system appropriate use of decision rules both to trigger/exclude need for testing gives you credit for complexity/risk.

I think HEART score gives a good framework and local standard of care to give reasonable, outpatient care for a subset of CP patients.
I certainly mention PERC and Wells Low Risk / DDIMER negative when I think it is relevant.
I like PECARN for the pedi-trauma, and frankly when you go through it with parents and discuss risk/benefit of CT the vast majority seem to like it as well.
I’m less into Nexus/ Canadian C-spine/CT head rules but occasional cite them in my MDM.
I typically note PESI/Modified PESI when I send PE home.

And of course, never become beholden to a decision rule. They are imperfect, and if your expertise (we are EXPERTS boys and girls) says no to use one in a case, then don’t…

 

[Apollyon]

Despite rusteds giggle at this comment, I absolutely take it into account. The 3rd trimester pregnant lady who was sent in with a positive dimer because some idiot NP ordered it for the chest pain that she had with coughing? Didn't scan.

For the three trimesters, the third trimester is the least susceptible to radiation damage to the fetus. The first trimester is the one where ionizing radiation is bad stuff; when, already, 33-40% of pregnancies will be lost due to gross genetic abnormalities, throwing the extra rads on there is bad juju.

 

[Birdstrike]

If

And of course, never become beholden to a decision rule. They are imperfect, and if your expertise (we are EXPERTS boys and girls) says no to use one in a case, then don’t…

That’s all I’m saying. The well-validated ones can be very good learning tools but all have pitfalls and cannot replace clinical judgment. If they could, you could put non-physicians in charge of all head traumas, PEs, and chest pains. If you haven’t seen a positive that was (or would have been) missed by a decision rule, you haven’t been practicing long enough.

 

[Arch Guillotti]

Jaw thrust with lots of pressure on the laryngospasm notch.

BVM them with a bag that has a peep valve on it.

If that doesn't work, push propofol and sux and intubate them.

Don't ventilate them. Attach the mask and form as tight a seal as possible. Relatively easy to do with the setup in the OR, not sure how well it would work with BVM. Idea is to create enough pressure to break spasm.

Also would probably try small amount of sux, (20 mg or so). Often that is enough to break the spasm.

 

[BoardingDoc]

Don't ventilate them. Attach the mask and form as tight a seal as possible. Relatively easy to do with the setup in the OR, not sure how well it would work with BVM. Idea is to create enough pressure to break spasm.

Also would probably try small amount of sux, (20 mg or so). Often that is enough to break the spasm.

I don't understand what you're saying re: don't ventilate but yes create pressure to break the spasm. I agree with creating pressure, that's the whole point of the peep valve I mentioned. Not sure how I would do that with a bvm and peep valve without, you know, squeezing the bag.

 

[GassYous]

I don't understand what you're saying re: don't ventilate but yes create pressure to break the spasm. I agree with creating pressure, that's the whole point of the peep valve I mentioned. Not sure how I would do that with a bvm and peep valve without, you know, squeezing the bag.

Do you need to squeeze the bag to create pressure?

 

[NITRAS]

I agree, because you're gonna spin 'em anyways. Good catch; my ass was being lazy.

Interesting case. Honestly, I’d repeat the d-Dimer. I’d sooner believe the lab screwed up than that a dimer was negative in a large PE.

 

[RustedFox]

Interesting case. Honestly, I’d repeat the d-Dimer. I’d sooner believe the lab screwed up than that a dimer was negative in a large PE.

This never would have occurred to me.
Hunh.

 

[NITRAS]

This never would have occurred to me.
Hunh.

I’ve seen lots of lab draw errors recently. I had a particular ED nurse draw labs diluted with saline two times in a row. Just like any complex process, errors happen. A lab draw often involves 3 or 4 separate people, and sometimes, machines or tubes are just busted. Times are tough right now.

 

[RustedFox]

I’ve seen lots of lab draw errors recently. I had a particular ED nurse draw labs diluted with saline two times in a row. Just like any complex process, errors happen. A lab draw often involves 3 or 4 separate people, and sometimes, machines or tubes are just busted. Times are tough right now.

So, let's explore this.
Now you have two different values.
Which one is the error; the one you don't like?

 

[NITRAS]

So, let's explore this.
Now you have two different values.
Which one is the error; the one you don't like?

A CMP diluted with normal saline will have super low potassium, calcium, bicarbonate and a very high chloride.
A person with a calcium of 4 or 5 should be super symptomatic. A K of 2 should have EKG changes.

Also, when you tell a nurse to redraw labs because you think there was IVF in it, usually they are careful not to have IVF in there. Rarely is this an issue upstairs because the nurses are not allowed to draw from IV’s, which the ED’s routinely.



And I always go with the answer that I like.

 

[RustedFox]

A CMP diluted with normal saline will have super low potassium, calcium, bicarbonate and a very high chloride.
A person with a calcium of 4 or 5 should be super symptomatic. A K of 2 should have EKG changes.

Also, when you tell a nurse to redraw labs because you think there was IVF in it, usually they are careful not to have IVF in there. Rarely is this an issue upstairs because the nurses are not allowed to draw from IV’s, which the ED’s routinely.



And I always go with the answer that I like.

... But the dimer.

Let's say 2nd value was 721.
What now; rubber match?

 

[NITRAS]

... But the dimer.

Let's say 2nd value was 721.
What now; rubber match?

Oh, honestly, if I was in the ED, I’d either scan then or not based on my gastalt. Spending time waiting for another lab test to result to do a CT scan sounds like a waste of time you don’t have in the ED. I was saying if you gave me this patient to admit who had a negative dimer and a positive CT scan, I’d repeat the dimer for the heck of it.

You know, one of those cerebral things, that internist do just because that don’t necessarily change management.

 

[RustedFox]

Oh, honestly, if I was in the ED, I’d either scan then or not based on my gastalt. Spending time waiting for another lab test to result to do a CT scan sounds like a waste of time you don’t have in the ED. I was saying if you gave me this patient to admit who had a negative dimer and a positive CT scan, I’d repeat the dimer for the heck of it.

You know, one of those cerebral things, that internist do just because that don’t necessarily change management.

Lol.
IM-EM foibles aside, I'm actually kind of jealous of you IM folk and your skillset, and your approach. Maybe it's a "grass is always greener" situation, but I really wish I knew more about bread-and-butter IM. Example: I can't interpret thyroid labs anymore and I really never could.

It's almost like, I know what I don't know and don't go around doing things I don't know; but I know that I can know them and I want to know them because I feel like I should know them.

You know?

 

[Arch Guillotti]

I don't understand what you're saying re: don't ventilate but yes create pressure to break the spasm. I agree with creating pressure, that's the whole point of the peep valve I mentioned. Not sure how I would do that with a bvm and peep valve without, you know, squeezing the bag.

I don't know that you can do it. The circuits we have in the OR allow you to dial in the amount of pressure that you want. Kids are the most likely to spasm when emerging from anesthesia. Mistake that I have seen before is CRNA trying to ventilate to break spasm. Instead the solution is to apply an airtight mask seal to the patient and dial the pressure in to about 20. If the circuit is leakproof our version of the ambu bag will tense up and create pressure in the system akin to peep. Gently squeezing the bag and holding it increases the pressure. When the spasm breaks you can see and feel the bag deflate as the child takes a breath at which point the pressure valve should be dialed back down to a low level. Madly squeezing the bag against a closed glottis isn't likely to help much.

 

[BoardingDoc]

I don't know that you can do it. The circuits we have in the OR allow you to dial in the amount of pressure that you want. Kids are the most likely to spasm when emerging from anesthesia. Mistake that I have seen before is CRNA trying to ventilate to break spasm. Instead the solution is to apply an airtight mask seal to the patient and dial the pressure in to about 20. If the circuit is leakproof our version of the ambu bag will tense up and create pressure in the system akin to peep. Gently squeezing the bag and holding it increases the pressure. When the spasm breaks you can see and feel the bag deflate as the child takes a breath at which point the pressure valve should be dialed back down to a low level. Madly squeezing the bag against a closed glottis isn't likely to help much.

Interesting. My understanding of our peep valves is that you squeeze the bag and as long as you have a good seal you will eventually build up pressure to whatever you've set the valve to. I suppose you could get a good seal and then pump once or twice in order to get the pressure up and then simply stop bagging. The problem is that I don't think there's a way to see how much pressure is actually being delivered at any given moment. If you have a leak, you wouldn't know it and wouldn't be creating new pressure without squeezing the bag. I suppose some pressure likely comes from the O2 line as well, but I have no idea how much that is or if it's clinically significant.

I thankfully haven't run into this issue in the ED but my game plan until now had always been to bvm with the peep valve set to something high and do the pressure point. If no luck, paralyze and intubate. I like the idea or trying 20mg of sux and bagging through it, with the obvious plan of simply pushing a full 1.5/kg 30 seconds later and intubating if that doesn't work.

I am curious as to how much pressure you generate in the mask with a peep valve on and simply letting the O2 run through the bag assuming you have a solid seal.

 

[PianoMedic]

Interesting. My understanding of our peep valves is that you squeeze the bag and as long as you have a good seal you will eventually build up pressure to whatever you've set the valve to. I suppose you could get a good seal and then pump once or twice in order to get the pressure up and then simply stop bagging. The problem is that I don't think there's a way to see how much pressure is actually being delivered at any given moment. If you have a leak, you wouldn't know it and wouldn't be creating new pressure without squeezing the bag. I suppose some pressure likely comes from the O2 line as well, but I have no idea how much that is or if it's clinically significant.

I thankfully haven't run into this issue in the ED but my game plan until now had always been to bvm with the peep valve set to something high and do the pressure point. If no luck, paralyze and intubate. I like the idea or trying 20mg of sux and bagging through it, with the obvious plan of simply pushing a full 1.5/kg 30 seconds later and intubating if that doesn't work.

I am curious as to how much pressure you generate in the mask with a peep valve on and simply letting the O2 run through the bag assuming you have a solid seal.

Some of my hospital’s pedi ambu bags also have a pop off valve so your airway pressure isn’t over a certain amount. So you have to dial that up some (think I went to 30 on that) along with your peep valve. We did squeeze the bag a couple times after getting a good seal. Worked in one of my cases, the first time we were intubating and bagging did not work. Third time notch pressure worked on its own.

 

[WilcoWorld]

So, let's explore this.
Now you have two different values.
Which one is the error; the one you don't like?

The one that doesn't fit the contextual puzzle.

 

[WilcoWorld]

I don't know that you can do it. The circuits we have in the OR allow you to dial in the amount of pressure that you want. Kids are the most likely to spasm when emerging from anesthesia. Mistake that I have seen before is CRNA trying to ventilate to break spasm. Instead the solution is to apply an airtight mask seal to the patient and dial the pressure in to about 20. If the circuit is leakproof our version of the ambu bag will tense up and create pressure in the system akin to peep. Gently squeezing the bag and holding it increases the pressure. When the spasm breaks you can see and feel the bag deflate as the child takes a breath at which point the pressure valve should be dialed back down to a low level. Madly squeezing the bag against a closed glottis isn't likely to help much.

That makes much more sense now, thanks!

EM Docs: What they're saying is that when you have the anesthesia bag (not our ED/Ambulance self-expanding plastic bags) you let the pressure of the gas do the work. This accomplishes 2 things:

1 - This applies a steady unidirectional pressure to break the laryngospasm. Not a back and forth pressure differential.
2 - By "not ventilating" with a good seal you can feel the (anesthesia) bag fill up and get higher and higher pressure, until...the spasm breaks. So you can FEEL when the air is going in. Whereas with vigorous bagging it's hard to tell where that air is going.

 

[Janders]

Interesting. My understanding of our peep valves is that you squeeze the bag and as long as you have a good seal you will eventually build up pressure to whatever you've set the valve to. I suppose you could get a good seal and then pump once or twice in order to get the pressure up and then simply stop bagging. The problem is that I don't think there's a way to see how much pressure is actually being delivered at any given moment. If you have a leak, you wouldn't know it and wouldn't be creating new pressure without squeezing the bag. I suppose some pressure likely comes from the O2 line as well, but I have no idea how much that is or if it's clinically significant.

I thankfully haven't run into this issue in the ED but my game plan until now had always been to bvm with the peep valve set to something high and do the pressure point. If no luck, paralyze and intubate. I like the idea or trying 20mg of sux and bagging through it, with the obvious plan of simply pushing a full 1.5/kg 30 seconds later and intubating if that doesn't work.

I am curious as to how much pressure you generate in the mask with a peep valve on and simply letting the O2 run through the bag assuming you have a solid seal.

That makes much more sense now, thanks!

EM Docs: What they're saying is that when you have the anesthesia bag (not our ED/Ambulance self-expanding plastic bags) you let the pressure of the gas do the work. This accomplishes 2 things:

1 - This applies a steady unidirectional pressure to break the laryngospasm. Not a back and forth pressure differential.
2 - By "not ventilating" with a good seal you can feel the (anesthesia) bag fill up and get higher and higher pressure, until...the spasm breaks. So you can FEEL when the air is going in. Whereas with vigorous bagging it's hard to tell where that air is going.

Yeah the key here is that anesthesia machines and bags / circuits are markedly different that the self-inflating BMV in the ED hooked to 15L wall oxygen with a one-way pop-off valve and no PEEP control.

Weingart goes through turning one into basically a CPAP set up in his pre-oxy set up; If you set the PEEP valve to 10 AND have rather high flow oxygen entering the circuit (i.e. NC turned to 15L) with the mask sealed well over this, you get pressures from 6-10 through the patient's respiratory cycle. I suspect an approach like this would be reasonable with ketamine laryngo spasm, slowly dialing up the PEEP valve to increase pressure until you get success, but I've never tried it...

Preoxygenation, Reoxygenation and Deoxygenation

What is this page about? Scott Weingart, MD and Richard Levitan, MD published an article in the Annals of Emergency Medicine entitled Preoxygenation and

emcrit.org

 

[Janders]

My ketamine laryngospasms have been--
(1) So mild as to basically only caused 30s of minor stridor which got my pulse up but otherwise just repositioned the head/neck and monitored, and it went away. Good reminder to have everything in the room ready though...
(2) Moderate but in the setting of emergent IM ketamine, not pedi sedation. Broke with vigorous pressure point / jaw thrust combo (or went away on its own). Was very ready to RSI this adult if it didn't reverse rapidly...

 

[Arch Guillotti]

Some of my hospital’s pedi ambu bags also have a pop off valve so your airway pressure isn’t over a certain amount. So you have to dial that up some (think I went to 30 on that) along with your peep valve. We did squeeze the bag a couple times after getting a good seal. Worked in one of my cases, the first time we were intubating and bagging did not work. Third time notch pressure worked on its own.

There are all sorts of Mapleson circuits that can possibly be configured. Excruciatingly mind-numbing minutiae that anesthesia residents are forced to memorize. They all have a fresh gas flow and the most common ones have a valve to dial in the peep.

 

[RustedFox]

There are all sorts of Mapleson circuits that can possibly be configured. Excruciatingly mind-numbing minutiae that anesthesia residents are forced to memorize. They all have a fresh gas flow and the most common ones have a valve to dial in the peep.


View attachment 365047

Cool pictures, bro.
What's in the circle?

 

[Apollyon]

Cool pictures, bro.
What's in the circle?

I think that's the bag. You know, the anesthesia black ridged one? That one.

 

[Janders]

I think that's the bag. You know, the anesthesia black ridged one? That one.

Bingo. Note only one exit to that bag, no pop-off or 1-way exit valve etc

 

[RustedFox]

I think that's the bag. You know, the anesthesia black ridged one? That one.

Okay. What's the zig zaggy line?

 

[BoardingDoc]

Okay. What's the zig zaggy line?

Corrugated tubing

 

[RustedFox]

I think that's the bag. You know, the anesthesia black ridged one? That one.

Corrugated tubing

... and you guys took me seriously?!

Come on, you should know me better than that.

 

[TooMuchResearch]

Do you need to squeeze the bag to create pressure?

Yes. Our toys are not like your toys.

 

[TooMuchResearch]

Cool pictures, bro.
What's in the circle?

God.

 

[GassYous]

Yes. Our toys are not like your toys.

I thought with a peep valve and a solid flow it would keep the pressure up. I'm surprised you guys have so much laryngospasm with ketamine. I've given 15-50 iv for procedural sedation and 100-200 im many times and have not seen it.

 

[TooMuchResearch]

I thought with a peep valve and a solid flow it would keep the pressure up. I'm surprised you guys have so much laryngospasm with ketamine. I've given 15-50 iv for procedural sedation and 100-200 im many times and have not seen it.

I've actually never had a problem with it, but I know people who have encountered the issue.

 

[Old_Mil]

Decision rules, even the good ones, are on shaky ground Here's why:

-They are based on studies with patient populations with strict inclusion and exclusion criteria. When's the last time you read those critieria on the study where your decision rule was formulated? (Never, or if you did, you can't remember what they are). Does your patient fit the criteria?

-They are designed to be useful when you're uncertain with your clinical judgement. But they all have a poison pill that says something to the effect that "physician judgement" or "clinical gestalt" is required to make the rule work. The rule is essentially telling you, "If you're not sure, I'm not sure either." What good is that?

-Decision rules nearly always have some sort of cutoff that allows them to absolve them of responsibility when you use them and miss. "Might miss 1.8%" Sound familiar? How much confidence do you want to place in a rule that tells you 1 out of 55 of your patients you were pretty sure didn't have a PE are going to have one, even when you used their rule!?

If you have enough of a suspicion to pull out a decision rule, you probably should ordering a test, in my humble opinion.

Right or wrong, I usually pulled decision rules out of MD calc, filled them out, and pasted them directly into the chart to try and objectify something I ruled out without testing. I guess if I missed something, pointing out that I thought about it and went through an objective process to rule it out would be better than just saying "Well, I didn't think they had it" in a deposition. I sort of became a decision rule addict in the pursuit of defensive medicine that way.

 

[wareagle726]

I had a laryngospasm in a 6yo in residency that freaked me out with kids. Slow push, 1/kg. Tried Larson's point pressure, hard jaw thrust, Peep on BVM. Lost sats quick. Sux and tube. Since then I keep sux ready with almost all ketamine sedations in kids. Hasn't happened since through probably 50 peds sedations but I still have it ready in case.

 

[NYEMMED]

Nothing will make you respect the airway more, than a procedural sedation with laryngospasm

 

[GassYous]

I had a laryngospasm in a 6yo in residency that freaked me out with kids. Slow push, 1/kg. Tried Larson's point pressure, hard jaw thrust, Peep on BVM. Lost sats quick. Sux and tube. Since then I keep sux ready with almost all ketamine sedations in kids. Hasn't happened since through probably 50 peds sedations but I still have it ready in case.

Always have sux and atropine drawn up for kids

 

[wareagle726]

Just as a secondary thought, and I know this is not what this thread is about, if you're(cough cough) at a decently big place that doesn't have a PICU and have to intubate a kid for a sedation what would you do next? I haven't encountered this yet and would assume the easy button is transfer but I fee like letting the meds run their course and extubating wouldn't be too high risk right?