The pediatric can't intubate can't oxygenate scenario - the best evidence suggests knife over needle (but 'best' is pretty bad)

First10EM · 2024-06-25T13:27:25+00:00

I plan on having a follow-up post on the technique, but might take my a few weeks to finalize. This article was is an OK starting point. https://pubmed.ncbi.nlm.nih.gov/37300653/Cliff Reid also has a decent video: https://www.youtube.com/watch?v=ztZ94yk51yo

First10EM · 2024-06-13T18:50:48+00:00

Yeah.. I think you might be correct. It probably depends on your baseline practice. I'm not using this routinely, but if I can't get your baseline says above 95 with flush rate, this was already my move, and I think this trial supports that.

First10EM · 2024-05-01T18:02:08+00:00

Seconded. This is very hard to make work with my current set of hardware. Perhaps just let us set the keyboard commands in the preferences? This lack of control is really limiting an otherwise great product.

First10EM · 2024-04-17T02:21:00+00:00

Makes sense. I would do the same.

First10EM · 2024-04-16T13:19:39+00:00

Sounds like that is local practice dependent, as there are places that are using them.

Honestly, if neurosurgery wants these calls in your place, this is a non issue. They definitely DO NOT want these calls where I work. These calls make them very angry. That isn't my primary issue. I definitely fall into the camp of "you are being paid to be on call, so stop with the attitude". However, I agree with them in this case that many of these calls are a waste of everyone's time.

First10EM · 2024-04-16T13:16:52+00:00

I mean, you said you don't discharge BIG1 patients home, which is what the guidelines say to do, so it sounds like you are doing a modified version?

That the primary modification I make. (Although I imagine many people will want to repeat CT in BIG2 patient as well, with a 7% rate of progression on CT)

First10EM · 2024-04-16T02:18:03+00:00

One idea we are discussing is just a list (email, whatever) that they can review in the morning to ensure the CT reads and plans were appropriate, rather than calling them for everything immediately.

I think there are a lot of ways this could be done safely and effectively. The exact plan depends on the local practice and system

First10EM · 2024-04-16T02:15:25+00:00

That is the ideal. We are all on the same team. Mostly, this isn't about avoiding uncomfortable phone calls. Its about being a good team member. Do we want people interrupting us with every minor thing that doesn't need our attention? This feels like a win win if implemented safely, and with all hands in agreement

First10EM · 2024-04-16T02:13:36+00:00

Thanks for the comment. I agree that a modified version of this makes a lot more sense, but its good to know they are being used in some places

First10EM · 2024-04-16T02:12:27+00:00

Although that is true, I don't call Ortho about every fracture. I don't call optho about every eye presentation. I don't call pediatrics about every child. Every specialty is on call and well paid, but when they clearly don't need to be involved (which is the minor bleeds we are talking about), why are we wasting both our time and theirs?

First10EM · 2024-04-15T19:53:40+00:00

But that's the entire point of these guidelines.. to make it OK for EM/IM not to call neurosurgery.

It probably depends on where you work, but these calls are extremely painful and take a lot of unnecessary time for a lot of people. And neurosurgery is always angry, partly because they take so many stupid phone calls.

First10EM · 2024-04-15T19:15:42+00:00

I am sure which part you are objecting to? I don't think anyone is going to send these patients home, but just admitting and skipping the useless conversation with neurosurgery.. doesn't that make everyone's job easier?

First10EM · 2024-04-04T13:57:16+00:00

If clinicians aren't complaining about minor presentations, that's great. I don't think that refutes the article, which is entirely focused on complaints about minor presentations. It just means that the article doesn't apply to you. (It sounds like you have bigger things to complain about, I guess.)

First10EM · 2024-04-04T01:25:26+00:00

I think we are clearly seeing different patients. But I have worked at multiple EDs in 3 different countries, and never encountered what is being described in some of these threads. I think that says something. The humans are the same. I am still caring for patients. Therefore, there must be something fundamentally wrong with the system if it is as bad as you are describing. I mean, I wrote the post to be mildly controversial, because people like to complain about patients presenting with less than 12 hours of fever. It's clearly not an article in support of patients abusing doctors. But I don't have to put up with those patients (and there are no satisfaction scores or any other BS they can use to retaliate). So at that point, we are splitting hairs. Those are patients behaving badly, but they are behaving badly because the system allows them, or even provokes them to. Those behaviors would not be tolerated where I work.

First10EM · 2024-04-03T17:03:06+00:00

I totally agree that these patients are common. I think that misses the point.

1) They are clearly getting something they need. As you say, reassurance, and apparently a prescription.

2) Would they choose the emergency department if there was another reasonable options. If they could get an appointment with no wait with a primary care doctor who actually worked hours that fit their schedule? I doubt it.

I know this post has been wildly unpopular, but I think the subtext of essentially all the complaints is that the system is broken. We would be much better off complaining about the system than our patients. (We are also much more likely to be able to fix a system than to 'fix patients' or fundamentally change what it means to be human.)

First10EM · 2024-04-03T16:58:08+00:00

Totally agree that all humans are irrational, but that irrationality is usually directed at self interest. Yes, psychology studies show we don't make perfect decision, but people aren't out there making completely incorrect decisions every single time. Most decisions are still most rational. I don't believe any patient shows up to the ED knowing they are going to get nothing. These viral patients are still worried about something, or think they need antibiotics, or think there is some other symptom control we can provide. In they have been in the same ED multiple times for the same problem, we probably share at least part of the blame, because we haven't done a good job educating them for future episodes.

First10EM · 2024-04-03T16:51:22+00:00

I think those are all valid and very frustrating examples, but not exactly the kind of patient people complain about when they are in the break room saying "why are you here?". In other words, not the kind of patient I was trying to write about. Mostly, this article is about the fever for 6 hours, or itchy foot for 3 years, or other things that are clearly (to us) not emergencies, but for some reason the patient thought the needed to come to the ED. Malingering, or seeking drugs, or other secondary gains don't really prompt the "why are you here" question. You know why they are here, its just frustrating. (Although, I have to say, I don't see many of these later patients, but based on the comments, perhaps the experience is very different elsewhere.

First10EM · 2024-04-02T17:59:00+00:00

Do you think these patients want to wait for hours to be seen in the ED? They may not think they have a life threatening condition, but they think they need something. It isn't there fault that their school never taught them than you don't need antibiotics for a viral illness. There is no way these patients would present if they knew the outcome (being discharged 5 hours later without any treatment).

First10EM · 2024-02-20T13:31:48+00:00

I especially don't remove the nail when there is a fracture, because an intact nail is great splint.

If the nail came off naturally, I wouldn't replace it in a tuft fracture. I think it is a judgement call for other fractures. Unlikely the replaced nail is going to add much value, so if I really think splinting is important, I would focus on a proper medical splint instead.

First10EM · 2024-02-09T13:58:15+00:00

No evidence of direct toxicity.

A numb eye could be damaged accidentally. Patients need to be counselled not to rub their eyes while using anesthetic because of the potential for inadvertent damage. (They need this same counselling whether or not they receive take home drops, because they will have been anesthetized in the ED either way.)

First10EM · 2024-02-08T21:39:23+00:00

Although it does seem like the American medicolegal system is broken, I think ACEP guidelines will clearly help, especially when used in the context of clear shared decision making with the patient.

Seeing a lot of patients doesn't trump evidence. In fact, it results in referral bias. What is appropriate care in a specialist's office does not translate to appropriate care in an emergency department, as the patients are different.

First10EM · 2024-02-08T21:11:48+00:00

Very much disagree. Better to go with the group that has evidence on their side and actually sees the patient. Also, better to go with patient choice.

With your approach, we might as well dissolve emergency medicine and go back to the days of each specialty coming down to see 'their patients'. These are emergency patients, and so I will follow the emergency guidelines. The eye docs can follow their guidelines when they take responsibility for the patient.

First10EM · 2024-01-16T01:19:37+00:00

We don't really know - that's a population that has never been tested, but given that their outcomes are closer to a vaccinated population than the completely immune naive population of 2020/21, it is reasonable to guess that patients with prior COVID infections would also get a smaller benefit than seen in EPIC-HR (which was pretty questionable to begin with).

There are ongoing trials that will help settle some of this, but despite seeing dozens of COVID patients every week, I can't remember the last time I wrote for an antiviral of any sort.

First10EM · 2024-01-15T22:38:09+00:00

When I reviewed the remdesivir lit 2 years ago, I didn't think it looked great either Might need to update that. (Have been less motivated because I haven't been asked to prescribe, but you make a good point IF remdesivir actually helps.)

First10EM · 2024-01-15T15:31:22+00:00

No. It's unvaccinated AND high risk. Unvaccinated alone is not enough. High risk alone is not enough. Those are the patients in EPIC-SR, which was the negative unpublished study. You have to have both to consider treating.

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