The following slideset was delivered to the EM Residency at Nassau University Medical Center on January 27, 2016. It is a resident level introduction to mechanical ventilation which includes basic trouble shooting but does not go into advanced ventilation strategies.
The Annals of Emergency Medicine will soon be publishing the following article:
The Ethics of Using the Recently Deceased to Instruct Residents in Cricothyrotomy by Dr. Andrew Makowski
— Casey Parker (@broomedocs) January 21, 2015
Followed by this, from Dr. Seth Trueger:
— Seth Trueger (@MDaware) January 21, 2015
Now, although I was happy to read the piece and felt that Dr. Makowski really did a great job of getting down to the key issues, I’ve begun to wonder. How common is the practice of performing invasive procedures on recently deceased patients in the Emergency Department? Have you seen this happen? Heard of it? Ever participated?
Please help us out by taking a minute to respond to this short poll (also embedded below). It’s just my attempt to get a sense of how the EM and Critical Care communities – at least those who are online – feel about the question.
~Many thanks to Dr’s Parker and Truger who took the time to give the survey a once-over prior to release.
If you have any trouble with the embedded form, just follow this link: http://goo.gl/forms/5CXxmDMXpC – please share with your friends!
The poll will be accepting responses until Feb. 6 at 23:59, US ET (GMT-5).
Slides from the session Jeremy Faust and I presented at Resuscitation 2014, including course faculty contact info:
— Steve Rowe (@Kangaroosteve) November 28, 2013
The responses were so amazingly useful that they just had be Storified for posterity (read on).
Checklists are hot.
In fact, they’re so hot that Dr. Atul Gawande (in addition to writing extensively about this in the academic and popular press) and colleagues have dedicated an entire website to the concept. They’ve even come up with a Checklist for Checklists (also, see their checklist Implementation Guide).
I’m a big believer in standardization and in the use of checklists when stakes are high and time is short. This isn’t a universal principle, of course. Medicine is not one-size-fits-all, and checklist overuse will just result in checklist fatigue. However, in the right setting, they should be used all the time, every time.
To create a practicable checklist, consider the following:
- Design each item to address a specific, actionable, critical safety step
- Make it short and easily understandable
- Utilize natural breaks in work-flow
- Build it in to your process and delegate a team member
- Review, Revise and Refine
Rapid Sequence Intubation (RSI) is one situation in Emergency Medicine in which preparation is king and there is zero tolerance for error. In our own small slice of the living medical literature – the FOAMiverse – Dr. Scott Weingart (@EMcrit) and others have been aggressively promoting the use of RSI checklists. If you don’t buy it, listen to this talk by Dr. Minh Le Cong from SMACC 2013 about “Airway Clean Kills“. Intubation offers you many ways to kill your patient. Checklists can help avoid some of them.
The traditional print literature has yet to catch on and so there doesn’t seem to be a specific evidence base for ED RSI checklists (except this Pediatric EM abstract), but it wouldn’t be surprising if the topic starts trending soon. Some discussion already exists in the Anesthesia and Critical Care literature around intubation checklists. The Royal College of Anesthetists even describes an RSI checklist for ED’s and ICU’s in NAP4.
See below for the Storified conversation between Steve Rowe and some other very smart people. After you’ve clicked through the links and looked at all 5 checklists, be sure to review these two sites for a glut of RSI safety:
- Airway Checklist Practicalities by Dr. Yen Chow (@TBayEDguy), on PHARM
- EMcrit Podcast 92: Intubation Checklist
(some of the many contributors to Wednesday’s #ACEP13 twitter feed – thank you!)
Day 3 by the Numbers
3 million impressions
Categories (Storified tweets above – hover over photos to see text – at bottom of page, and here)
- Critical care
- Mechanical Ventilation
- Giving a Good Talk
- Policy and Practice
- “Hofkata” (Jerry Hoffman + Rick Bukata)
- Subarachnoid Hemorrhage
- Pediatric EM/CC
- Drugs of Abuse
Stuff I learned:
- ACEP is reconsidering the tPA policy, there will be a comment period (see Angela Gardner’s tweets)
- A ton of great stuff from the Hof-Kata session.
- Must work to reduce the risk of post-ROSC hyperoxia. In general, dial down FiO2 to 60% as soon as tolerated by pt. (keep pt sat around 94%, no need to get to 100%, may be harmful
- Hold off on insulin in DKA until you check a K (and start fluid resuscitation)
- There is now evidence for push dose pressors (citations on Storify)
- Great review of IO’s (humeral allows for larger volumes, needs longer needle, etc)
- MOPETT Trial discussion
- How to make cornstarch based gel for US (thanks to APousson)
- Review of mechanical ventilation settings
- Benign coughs 2/2 URI’s may last around 18 days, back pain can linger 3 months…Must align patient expectations.
- The huge of amount of $$$ journals make off of pharmaceutical industry requests for reprints.
- Lack of evidence for Tamiflu
- All sorts of SAH stuff…
- And so much more…
A full transcript of yesterday’s tweets is available via Symplur at: http://bit.ly/19PkpJf Bodymender has also done it again. See his high-yield pearls at: http://storify.com/Bodymender_n_ED/acep13-day-3 One of the most important quotes:
ACEP Day 2, by the numbers:
3.2 million impressions
Avg of 124 tweets/hour
Categories (Storified posts above, and at bottom of page)
- Critical Care
- Pediatric EM
- Policy & Practice
- Tox/EtOH Withdrawal
- End of Life
What I learned from yesterday’s feed:
- Everybody wants a photo with Joe Lex (see examples on Storify)
- Hands-on defibrillation can be safe. Be sure to look at the literature though. (references on Storify)
- Benzo’s may increases delirium in critical patients, consider alternate Rx, such a Dexmedetomidine or Propofol
- Should assign staff member to be with family to answer questions when watching resuscitation (I like to assign a clinical member of the care team, when possible)
- Hetastarch = bad
- We can (and should) do something to prevent VAP starting in the ED
- Ultrasound first for infant/child abdominal pain, if must CT use low radiation dose protocol
- Oral 2% lidocaine for hiccups?
- Lots of great ENT tips
- Patients think well-dressed docs are smarter, but prefer EP in scrubs
- A. Fib can be dischargeable
- PE also?
- And so much more it’s ridiculous.
Another Resource If you need to read more, visit the Symplur transcript for the 24 hour period starting 0:01 on Oct. 15th. There are plenty of gaps both on Twitter and on Storify for some reason, but this seems complete: http://bit.ly/16gSBNM Photo by Courtney Gebben