Interesting/controversial EM topics

[jumponit]

Hi everyone,

I'm a second year resident in EM, and we are required to prepare a presentation for our residency class, which needs to last about an hour.

I've hit a writer's block and can't seem to think up any good, interesting/controversial topics, and I was hoping you guys could help me out.

I'm not interested in doing a case presentation, just wanted to get some ideas and brainstorming ideas out there from you guys, any help would be appreciated!

thanks!

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[Seaglass]

Try looking up studies on the utility of oral contrast in CT, or d-dimer for aortic dissection.

 

[Jeff698]

How about something really exciting like the true sensitivity/specificity of common ED tests? Say, strep or rapid flu?

How about NNT for things we all assume are gospel?

Take care,
Jeff

 

[Arcan57]

Antibiotics in adults for strep throat...

 

[Jeff698]

Tamiflu for influenza-like illnesses (or culture confirmed flu, for that matter)

Boarding admitted patients in in-patient hallways instead of in the ED (great article in this months Annals, BTW).

Use of physician triage which provides medical screening exams only prior to payment vs referral to clinic for non-emergent needs.

Paramedic initiation of cath lab from the field in STEMI patients.

Take care,
Jeff

 

[southerndoc]

Paramedic initiation of cath lab from the field in STEMI patients

We've taken it a step further. Paramedics fax us a 12-lead EKG, and if they're having a STEMI, they go directly from the ambulance bay to the cath lab. They don't stop in the ER and are never evaluated by an emergency physician (unless there is a delay in the cath lab).

 

[dmitrinyr]

We've taken it a step further. Paramedics fax us a 12-lead EKG, and if they're having a STEMI, they go directly from the ambulance bay to the cath lab. They don't stop in the ER and are never evaluated by an emergency physician (unless there is a delay in the cath lab).

This may be a stupid questions, as I've never seen this being done before, but where do the paramedics fax you the 12-lead ECG from? Do they have a fax machine on the rig connected to the 12-lead?

In these situations, do you just go by the H & P of the paramedic team in assessing that you in fact have a STEMI going on instead of all the various DDx of ST elevations (given that an ED physician does not actually get to talk and examine the pt prior to the pt going to the cath lab)?

Also, in the cases that go straight up, are the paramedics able to give all of the necessary meds prior to a cath or are the patient's given these meds while on the way up to cath lab or while in the cath lab?

Thanks.

 

[southerndoc]

This may be a stupid questions, as I've never seen this being done before, but where do the paramedics fax you the 12-lead ECG from? Do they have a fax machine on the rig connected to the 12-lead?

In these situations, do you just go by the H & P of the paramedic team in assessing that you in fact have a STEMI going on instead of all the various DDx of ST elevations (given that an ED physician does not actually get to talk and examine the pt prior to the pt going to the cath lab)?

Also, in the cases that go straight up, are the paramedics able to give all of the necessary meds prior to a cath or are the patient's given these meds while on the way up to cath lab or while in the cath lab?

Thanks.

The 12-lead ECG machines have built-in fax capability. It's faxed to our communications center, where an ER doc reviews the EKG.

If it meets STEMI criteria, the cath lab is notified.

Paramedics initiate treatment with aspirin and clopidogrel (don't ask, but they load with 300 mg). They also administer nitroglycerin, morphine, and oxygen. They do not initiate heparin (which really does nothing for an acute clot; it only prevents promulgation of existing clot).

There isn't much in the differential for STEMI's. The occasional aortic dissection can present in such a way. However, the cardiologists routinely do a screening aortagram as part of their caths. Pericarditis won't present in an anatomical pattern, and if it did, then I would send the patient to the cath lab if I were evaluating them. Prinzmetal's angina would still go to the cath lab if it's in an anatomical distribution.

We rarely get much of a history on these patients. Often times the EKG is shown to us and we say "STEMI" and the nurse sends it to the cath lab. Actually during the day when we have a bunch of cardiologists there, the EKG is actually faxed directly to the cath lab where the secretary takes it to one of the interventionalists that is in-house. During the day we don't even see the EKG's 90% of the time.

By the way, we have some impressive door-to-balloon times with this strategy.

 

[dmitrinyr]

By the way, we have some impressive door-to-balloon times with this strategy.

Given that they go directly from EMS to cath lab, I bet you do. Thanks for the reply southerndoc. I was curious if there has been any research evaluating this route to cath lab vs. regular one in which they get examined by an EM doc or triage nurse and AMI team gets called? Also, do many other places use this method? How long have you guys had this in protocol?

 

[southerndoc]

Given that they go directly from EMS to cath lab, I bet you do. Thanks for the reply southerndoc. I was curious if there has been any research evaluating this route to cath lab vs. regular one in which they get examined by an EM doc or triage nurse and AMI team gets called? Also, do many other places use this method? How long have you guys had this in protocol?

We've had it for about 6 months. The cardiologists are keeping numbers, and we have a research nurse, but I'm not sure if it's a formal study or if it's just for in-house numbers.

I'm sure there are other places that are doing it. I don't think we are pioneering the concept. Just haven't heard of anyone else doing it, but I imagine that our cardiologists got the idea somewhere (they were the ones who approached us with the idea so we could cut the door-to-balloon times).

 

[SoCuteMD]

We've taken it a step further. Paramedics fax us a 12-lead EKG, and if they're having a STEMI, they go directly from the ambulance bay to the cath lab. They don't stop in the ER and are never evaluated by an emergency physician (unless there is a delay in the cath lab).

What about the rare STEMI who is having an aortic dissection? Do they get a chest film, etc. before they are given heparin, integrillin, Plavix, etc.?

 

[southerndoc]

What about the rare STEMI who is having an aortic dissection? Do they get a chest film, etc. before they are given heparin, integrillin, Plavix, etc.?

In the field, no. The same is true of the pre-hospital providers that administer single dose reteplase due to lengthy transports to the cath lab.

Even in the ER, unless the clinical picture warrants it (i.e., tearing chest pain radiating to back), heparin is initiated prior to a chest x-ray.

 

[WilcoWorld]

In the field, no. The same is true of the pre-hospital providers that administer single dose reteplase due to lengthy transports to the cath lab.

Even in the ER, unless the clinical picture warrants it (i.e., tearing chest pain radiating to back), heparin is initiated prior to a chest x-ray.

The heparin I'm OK with - it's the clopidogrel before an MD evaluation that worries me.

 

[BADMD]

I've hit a writer's block and can't seem to think up any good, interesting/controversial topics, and I was hoping you guys could help me out.

tPA for stroke...

 

[La Fiera]

From a more administrative perspective,
How about Pres Gainey scores,
or Midlevels in the ED (am currently a little PO'ed at PA's) because ED physicians are responsible for everything that they do ultimately, but yet many hospitals/groups chose to staff the ED with them because its cheaper. I heard that some states are now having PA's work independently, and completely under their own lisence, but I don't know which states.

 

[Arcan57]

tPA for stroke...

You're kidding, right?

 

[Char]

You're kidding, right?

I agree with BADMD....it's a controversial subject.

 

[roja]

tPA for stroke...

My favorite controversial topic!
(if you aren't sure, check it out... there are many interesting and valid issues surrounding bias, stratification and combined outcome datapoints... not to mention, even if you ignore all those issues, weigh the NNT vs NNH. )


New controversial topic: coronary CTA

 

[dlung]

Calcium in dig toxicity -- debunked but few people know about it
B-blockers in cocaine-assoc chest pain
NG/OG tubes in corrosive ingestions
Physostigmine in patients with anticholinergic sx
Dialysis for severe VPA overdose
Dialysis for lithium intoxication
Charcoal (provocative article out of Sri Lanka in the Lancet last year)

 

[Hamhock]

Calcium in dig toxicity -- debunked but few people know about it
B-blockers in cocaine-assoc chest pain
NG/OG tubes in corrosive ingestions
Physostigmine in patients with anticholinergic sx
Dialysis for severe VPA overdose
Dialysis for lithium intoxication
Charcoal (provocative article out of Sri Lanka in the Lancet last year)

tox intox!!!!