What's changed in EM? What's the same?

[Birdstrike]

It's been over 5 years since my last shift in an ED. I don't come on SDN or this forum that much anymore (not sure I'm much missed.) But I was wondering, what's changed in EM in the last five years? Anything for the better? Anything worse? Or just, more of the same?

Regardless, cheers to the old crew from SDN EM 2010-2013. You're missed on this end.


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[WilcoWorld]

The patients.

They're always changing, and they always stay the same.

 

[RustedFox]

What's New: Clot retrieval for strokes is cool, and seems to work.
What's not: tPA. Lolz.

 

[WilcoWorld]

New therapies (some of which are revived oldies):

TXA for epistaxis.
IV lidocaine for pain.
Cipro for simple UTI is out.
One-and-done dexamathasome for asthma exacerbations.
Outpatient treatment for PE.
Some EMS crews are giving whopping doses of ketamine in the field for agitated delirium.

 

[goodoldalky]

.

 

[ERDude]

Some EMS crews are giving whopping doses of ketamine in the field for agitated delirium.

Just yesterday I had EMS give a "sub-dissociative" dose of ketamine (10mg) in an 80 yo lady with a hip fracture in lieu of any opiates. Interestingly she was completely dissociated for about 30 min after arrival and had a mild emergence reaction that resolved within about an hour. First time I've seen EMS give ketamine as first line analgesic (and frankly was not the right call - opiate worked much better with less side effect in this patient).

 

[Psai]

Just yesterday I had EMS give a "sub-dissociative" dose of ketamine (10mg) in an 80 yo lady with a hip fracture in lieu of any opiates. Interestingly she was completely dissociated for about 30 min after arrival and had a mild emergence reaction that resolved within about an hour. First time I've seen EMS give ketamine as first line analgesic (and frankly was not the right call - opiate worked much better with less side effect in this patient).

wtf? Why do we let people who don't know what they're doing do these things?

 

[swamprat]

wtf? Why do we let people who don't know what they're doing do these things?

Yeah I think short of being hours from a hospital EMS should be scoop and go short of like acute respiratory distress (and even then..) or codes. I work in a city where there are probably 20 hospitals both big academic places and community places. Your never more than a mile from a hospital.. EMS gave an 18 year old 100 of fentanyl for back pain that occurred when he twisted wrong playing basketball. I was so pissed off. Now I can understand obvious deformity of a leg of something but that should be excluded from their protocol


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[Everglide]

Yeah I think short of being hours from a hospital EMS should be scoop and go short of like acute respiratory distress (and even then..) or codes. I work in a city where there are probably 20 hospitals both big academic places and community places. Your never more than a mile from a hospital.. EMS gave an 18 year old 100 of fentanyl for back pain that occurred when he twisted wrong playing basketball. I was so pissed off. Now I can understand obvious deformity of a leg of something but that should be excluded from their protocol


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Our EMS crews do the same. 100 of fentanyl for basically anything. Partly because they're graded on if they gave pain control and if it worked or not. Hooray metrics.

I think something new is outpatient treatment of not only PE but basically all DVTs (assuming you start anti-coagulation at all)

 

[winkleweizen]

Yeah I think short of being hours from a hospital EMS should be scoop and go short of like acute respiratory distress (and even then..) or codes. I work in a city where there are probably 20 hospitals both big academic places and community places. Your never more than a mile from a hospital.. EMS gave an 18 year old 100 of fentanyl for back pain that occurred when he twisted wrong playing basketball. I was so pissed off. Now I can understand obvious deformity of a leg of something but that should be excluded from their protocol


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We had ems give a 93 year old man 100 of fentanyl for hip pain. Kicker, the guy was walking on his hip. Shortly after they gave it, he goes apneic and pulseless. Get him back but he dies 12 hours later. Frustrating.

 

[WilcoWorld]

Just yesterday I had EMS give a "sub-dissociative" dose of ketamine (10mg) in an 80 yo lady with a hip fracture in lieu of any opiates. Interestingly she was completely dissociated for about 30 min after arrival and had a mild emergence reaction that resolved within about an hour. First time I've seen EMS give ketamine as first line analgesic (and frankly was not the right call - opiate worked much better with less side effect in this patient).

Interesting - did you scan her head? I probably would've if an altered 80 yo with a hip fx showed up in my ED. Then I'd notice "ketamine 10mg" on the run sheet a few minutes after the CT was done... If you spared her the CT with close observation, hats off to you.

 

[WilcoWorld]

Whoops, didn't mean to turn this into an EMS bashing thread. I think field ketamine for agitated delirium is a pretty decent strategy. LDK in LOL's with hip fractures and fentanyl for everyone? Not so much.

 

[ERDude]

Interesting - did you scan her head? I probably would've if an altered 80 yo with a hip fx showed up in my ED. Then I'd notice "ketamine 10mg" on the run sheet a few minutes after the CT was done... If you spared her the CT with close observation, hats off to you.

I didn't scan b/c RN told me before I even walked in the room "they gave her ketamine and she's out of it". There was a witness that said no head injury and exam was normal so felt comfortable waiting an hour.

 

[The White Coat Investor]

The angst about CMG takeover of SDGs has multiplied about 5 fold. It was always there before, but it seems like a big gorilla looming over the entire field right now. I hope to see some reversal or at least slowing of the trend before it becomes impossible to work for an SDG anywhere.

The quality metrics seem particularly confusing the last couple of years.

Doing more CT scans and MRIs than ever. Man does everyone love imaging. I had four MRIs in one shift the other day. 10 years ago I'd go a month without one.

 

[coachB]

The angst about CMG takeover of SDGs has multiplied about 5 fold. It was always there before, but it seems like a big gorilla looming over the entire field right now. I hope to see some reversal or at least slowing of the trend before it becomes impossible to work for an SDG anywhere.

The quality metrics seem particularly confusing the last couple of years.

Doing more CT scans and MRIs than ever. Man does everyone love imaging. I had four MRIs in one shift the other day. 10 years ago I'd go a month without one.

The horse was out of the barn at least five years ago, but you are right, the pace has accelerated dramatically. You are in a unique environment and may last a while, but there aren't many places like that.

Most "quality metrics" don't seem to have much to do with quality and often lead to patient harm.

 

[Sightless]

Doing more CT scans and MRIs than ever. Man does everyone love imaging. I had four MRIs in one shift the other day. 10 years ago I'd go a month without one.

As a rads resident I'm curious- why do you think this is? Shift in diagnostic standards? Consultant expectations? Changes in imaging availability?

 

[Tiger26]

As a rads resident I'm curious- why do you think this is? Shift in diagnostic standards? Consultant expectations? Changes in imaging availability?

Interesting--I bet I don't do 4 MRIs in a year. I do order a fair amount of CTs. A lot of it has to do with the acuity

 

[BAM!]

As a rads resident I'm curious- why do you think this is? Shift in diagnostic standards? Consultant expectations? Changes in imaging availability?

It's the same reason you write on every CXR interpretation, "...small area of linear opacities at lung bases bilaterally, likely atelectasis. Cannot exclude underlying infection. Clinically correlate."

 

[BAM!]

Interesting--I bet I don't do 4 MRIs in a year. I do order a fair amount of CTs. A lot of it has to do with the acuity

I think it has more to do with expectations of patients, lawyers, consultants, and your hospital in general. At my old shop, MRI was only available at certain hours of the day if you pulled strings with the techs and their insurance was correct. I probably did ~2 MRIs per year. At my current place, MRI is readily available. Sometimes I can get one faster than a CT depending on the queue. I probably order 1-2 per month.

 

[WilcoWorld]

As a rads resident I'm curious- why do you think this is? Shift in diagnostic standards? Consultant expectations? Changes in imaging availability?

In my environment (a stroke center) it's a focus on stroke care that's driving most of the emergent MRI's. Even though the MRI is not necessary to make most of the emergent decisions...

 

[The White Coat Investor]

As a rads resident I'm curious- why do you think this is? Shift in diagnostic standards? Consultant expectations? Changes in imaging availability?

More normal for me is probably 1-2 a month, that's why 4 in a shift was crazy. But you basically can't call a neurologist without having done an MRI of the brain without contrast and some sort of head/neck vessel imaging study (CTA/MRA). Plus you add in the low back pains with weakness or numbness or incontinence and the occasional "pregnant, concern for appy" and there you are. So yes, it's availability, it's a shift in practice, it's consultant desire, it's patient desire. I'm still not doing "convenience care knee and shoulder MRIs" but it's still a lot more than I used to.

 

[The White Coat Investor]

In my environment (a stroke center) it's a focus on stroke care that's driving most of the emergent MRI's. Even though the MRI is not necessary to make most of the emergent decisions...

Right. Now I get a patient who's six hours out from a stroke and he gets an MR brain without, CT head without, and CTA head and neck. And that's a patient that's only going to get an aspirin, a statin and rehab.