Tag Archives: EM Mindset

EM Mindset: Longevity

Author: Loice A. Swisher, MD (EM Attending Physician, Mercy Philadelphia Hospital, Drexel University, College of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

It was the waning few hours of my 3rd year resident’s sixth twelve hour shift.  There were a handful of drunken men sleeping on stretchers, likely to metabolize to freedom by the time the sun rose.  A couple asthmatics were sitting on chairs getting a breathing treatment, as they had run out of their inhalers.  A patient with knee pain for two years was just registering.  Then the ambulance doors opened letting forth sounds that would put screaming banshees to shame.  The accompanying officers in blue yelled, “running in and out of traffic naked; probably PCP.”  The resident, who had been doing admirably, sputtered “How have you been doing this for a quarter of a century?  How does this not get to you? “Her eyes silently pleaded, “What is the secret?”

Sure, the question regarding burnout was frequently bantered about thirty years ago when I was a 3rd year medical student considering this new specialty as my career.  The ‘party line’ so to speak was that few in emergency medicine at that time actually chose and trained for this field.  It was likely many, if not most, came to EM after ‘burning out’ in their chosen specialty.  Thus, they were already essentially behind the 8-ball when they moved their job to the emergency department.  We wouldn’t be at such risk.  We were going into this with eyes wide open.  We were trained for exactly the situations we would encounter.  We would know all the pitfalls, plateaus, and rewards.  We would be able to deftly negotiate the punishment of shiftwork, chaos, and lack of control to be able to leave the hospital enjoying life without being on call.  We got this.

Burnout has increasingly entered conversation, ever since the landmark 2012 article by Shanafelt showing nearly half of physicians at that time suffered from at least one symptom of burnout [1].  Since that time emergency medicine has consistently taken either the first or second spot within the house of medicine [2,3,4,5].  I was wrong.  We don’t ‘got this’.

The resident’s question was a fair one.  How does one have longevity and sustain passion in this line of work?  How do we avoid burnout from the systemic pressures piled on us?  How do we combat compassion fatigue or PTSD from constant flow of people being seen on the worst days of their lives?

At that moment, I desperately wished I had an answer.  Given the luxury of time for reflection, I came up with my top three.

  1. Find a passion: This is true both within and outside of work. I love to travel.  It gives me something to plan and dream about.  It is an identity outside the hospital.  What matters most is that it is something that brings you satisfaction and a sense of joy or worth.
  1. Identify someone to talk to: There is tough stuff in what we do. Sharing stories can decrease the intensity of emotions.  Knowing one is not alone is key to human existence.
  1. Carefully craft your mantras: A mantra is generally thought to be a repeated word or phrase that is a ‘sacred utterance’ which one tells themselves. It comes from “man” for mind and “tra’ for transport.  Thus, these words transport the mind to a vantage point with which we view the world.  The words we tell ourselves can change the way we see the world.

Returning to that resident, I wanted to say there are several things that keep me doing this, but in those moments the strongest one is the soundtrack in my mind.  You can create phrases that make patients seem like enemies, or you can develop others that reorient the world.

When those ambulance doors open unleashing ungodly sounds, my first thought is, “sounds like one of my kids.”  When I get out of my car for my shift I tell myself, “Tonight I have the opportunity to relieve pain and suffering. What could be better than that?”  Throughout the shift I tell myself “Emergency medicine is the last best place in medicine.”  And I mean every single one of them.

References / Further Reading:

[1] Shanafelt TD, Boone S, Tan L, et al.   Burnout and satisfaction with work-life balance among US physicians related to the general US populations. Arch Intern Med. 2012 Oct:172(18)1377-1385.

[2]http://www.medscape.com/features/slideshow/lifestyle/2017/overview accessed March 8, 2017.

[3]http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=2 accessed March 8, 2017.

[4]http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#2 accessed March 8, 2017.

[5]http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 accessed March 8, 2017.

EM Mindset: Reading My Mind

Author: Judith E. Tintinalli, MD MS (Professor of EM / Chair Emeritus, Department of EM, University of North Carolina) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

A style of working, teaching, and learning in Emergency Medicine takes time to develop.   We don’t get much opportunity to see how our colleagues operate, except perhaps on change-over rounds, which are always pressed for time, and which don’t allow for discussions about why different attendings do things differently.  I’ve always thought of myself as a middle-of-the roader in our group: middle in terms of times, patients/hr, decisions to admit versus discharge. But I’m pretty good at documentation, work generally on the careful and compassionate side, can work at the speed of light when necessary, and have learned from the past so hopefully current mistakes are few and far between.

So, step into my office and I’ll share with you some of my habits, behaviors, and opinions that I’ve developed over the years.

Supervising Learners

Working in an academic medical center has great rewards.  Being surrounded by shadowers, medical students, and residents of all specialties keeps you on your toes. Medicine has moved from time-lapse to fast-forward, and residents who have recently completed inpatient rotations are terrific sources of changes in specialty practice patterns.  But the growing number of learners you are responsible for on a shift can be intellectually overwhelming and certainly slows down the process of patient care.  A different approach is needed for each level, so that one can loosen (but never eliminate) the level of supervision for the most senior learners.

I start my shifts explaining how to structure presentations. The goal is to get a good mental picture of the patient – ill-appearing, obese, amputee, in pain, blind or deaf, angry, demanding.  Then a concise statement of the triage note and patient’s problem, but with a listing of key meds/conditions that will affect the ED workup.  ‘This is a 65 year old patient with atrial fibrillation on Xarelto with 2 hrs of acute abdominal pain’.  Key meds for me are antithrombotics, immunosuppressives, steroids, insulin.  I’ll never forget a ‘routine’ intern presentation of a 65 year old woman who fell at home, and now had a femur fracture. When I went to evaluate her, I was aghast at not being told she had a heart transplant and had severe COPD requiring home oxygen.  How many times have I been told confidently that vital signs were ‘rock stable’, only to find a pulse rate of 120 or a BP of 230/170.

So, focused and concise presentations help a busy attending prioritize which patients need to be seen as soon as possible. They also teach learners how to present to consultants.

Teaching in the ED

There’s a growing body of EM literature that focuses on clinical teaching in the busy ED.  Each of us has to develop our own style.  I like to ask for the main, and then major differential diagnoses, before the learner spews out the orders, so the learner can demonstrate why each order is needed. I keep trying to minimize laboratory orders, but one of our jobs is to let each learner order stuff, and with experience, to be able to gain confidence in clinical judgement and stop ordering unnecessary labs and imaging. That is a trial and error process. One good tool is to ask the resident ‘If this patient came into your office, would you send them to the ED to get these lab tests or imaging?’

One of the best teaching tools I use is to ask a question that I myself cannot answer.  Like – ‘OK this person with prior DVT and PE is on Xarelto, and now we’re concerned about another PE. What’s the failure rate for Xarelto and does this patient have any risk factors for failure?’  Another tool is to come armed with a recent article you’ve read, ready to whip it out when needed.   For example, our residents like to order stress tests out of the ED for patients with low probability chest pain, because we have a protocol, but ask them ‘why’, ‘how’, or ‘what does it cost the patient’ and you’re met with silence.  So for a while I kept a copy of Long and Koyfman’s article  ‘Current Controversies in the Evaluation of Low Risk Chest Pain (JEM Dec 2016)’ in my doctor bag,  let them see the current data on the topic, and then give the opportunity to re-evaluate their decision.   Another one I kept with me recently was the recent study on single-dose decadron 12 mg po for adults with mild-moderate asthma.  As residents don’t read journals anymore, it gives them the opportunity to at least read a journal abstract.

Procedures and Consultations

In emergency medicine, we’ve structured our residency programs so the majority of learning and teaching is in tertiary care centers.  Consider the disadvantages: where specialty consultants are available 24/7, it can be a lot easier to call ortho to reduce a hip, evaluate a fracture or tap a joint, to call GU to place a difficult Coude catheter, or to have neurology decide who gets tPA for possible stroke.  The community EM practices that most of our residents will select after graduation will typically have a very limited menu of emergency consultants, and I’m not sure we are training them well for these environments.  I always have residents think through their treatment plans before calling the consultant, as this is their future reality.  I remember during the early days of EM training, moonlighting was really frowned upon.  The philosophy was that the only time anybody cared about resident learning was during residency, so every minute should be spent reading, seeing patients, and learning.  The medical environment has changed, and our senior residents get invaluable experience moonlighting that we cannot give them in a tertiary care environment.

Disposition and Follow-Up

This is where I think attendings and residents diverge.  I explain that everyone, learner or attending, has his or her own inherent ability to tolerate uncertainty.  If a resident strongly wants to admit a patient that I feel can be safely discharged, I challenge him or her to present the case to the admitting team. This gives a chance to practice skills needed in a community ED setting.  Another area of divergence is how far to go to exclude specific diagnoses in the ED. In our current medical care system, where so many patients have no insurance, giving them a clean bill of health in the ED means a lot. So ultrasounds, MRIs, and CT scans, and sometimes consultations in the ED to provide a clear follow-up plan, are more and more part of routine management.  Disposition requires a lot of stepped-thinking. Recently I took over a shift where a young Spanish-speaking woman came into the ED with a disc of a head CT identifying a brain tumor. Imaging had been done at an outside community hospital without neurosurgeons, and the patient was told to make an appointment with a neurosurgeon.  Mystified, she came into the ED.  Her discharge had already been written by the previous shift team, and the phone number of neurosurgery clinic was provided.  We held the discharge and consulted neurosurgery.  The CT was reviewed, an MRI was then done, decadron and Keppra were recommended by the neurosurgeon, and a clear follow-up was arranged in 3 days in neurosurgery clinic.  These steps would be very difficult to manage as an outpatient, where waits for an MRI can be weeks; payment is required before testing; the clinic appointment team may or may not speak Spanish; and it can take weeks to get an appointment in an overburdened neurosurgery clinic.  Another important principle I try to teach is ‘we cannot predict the future’.  Residents will sometimes say, oh, why get this specialized imaging; why call the consultant, they won’t do anything; why try for admission – there’s an easy answer.  I cannot predict the future – can you?

Why I love Emergency Medicine

A recent JAMA article reported that emergency medicine has the highest burn-out and fatigue rate of any other specialty.  If that is so, why are medical students flocking to our residency programs? Not every shift is wonderful – some are exhausting, filled with contentious problems or patients. Most times I look forward to a shift, but sometimes it is hard to put one foot in front of the other as I walk to my desk.  But I think all of us would rather be emergency physicians rather than anything else.  We have the unique ability to help patients when they are most vulnerable.  We have to establish rapport within minutes, not weeks or months.  We work in a terrific team environment.  We learn to be flexible, can calm down irritable consultants, and like to make fast decisions.  We can work a lot of shifts or fewer shifts. We don’t carry our patient burdens home with us. Life is good.

EM Mindset: the Fickle Gravity of Fear

Author: Shannon Moffett, MD (EM Attending Physician and Clerkship Director, Rutgers New Jersey Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Reading through my predecessors’ work on this topic, I am struck by the absence of any specific mention of fear. Perhaps it is because fear and anxiety, like bad odors, are omnipresent in the emergency department, and so we become accustomed to them.  Like city smog, the sulfur in your hometown’s tap water, or the pop-pop of gunfire outside your ambulance bay, live with anything long enough, and it becomes background.  Which is as it should be – on any given day, an EM doc should be blind to fear – examining fear on shift is as unhelpful as a lecture on gravitational acceleration during a tightrope act.

Or it would be, if fear were constant, like gravity: a steady tug on your arm as you intubate, the pit in your stomach the exact same depth day after day.  Which, for stretches, it is.

But conditions fluctuate during our medical high-wire acts, and our muscle tone varies. Often, the change in our conditioning is linear and slopes up.  We are scared the first time we stick a needle through the skin of another human being, the first time we order a paralytic, the first time we discharge a patient we haven’t diagnosed. But for long periods, we proceed in our fear-grapple like a baby hitting milestones – we cruise on by.

There comes a time – perhaps you are in that glorious period now – when you feel wary but confident; you have so much under your belt.  There is little that surprises you – you’ve learned from your mistakes, or been super-blessed and been able to learn from others’ mistakes (all the knowledge, none of the pain!).  You are a sprinter, not an aerialist – your movement is in a different plane.

And then, later, something happens – the earth tilts on its axis; you’re chucked into a human centrifuge; the bottom drops out and your epigastrium plunges into the canyon where your umbilicus once was, like a stone off a cliff. Suddenly, like an astronaut just back from the space station, your usual tasks take all your accessory muscles – “what if…?” whines incessantly in your head as you plan your work-ups, send patients to the floor or home on the bus.  As with food-poisoning, it’s usually hard to pinpoint the source of the disturbance.

Or worse – you develop one of the flavors of emergentologist’s periodic paralysis: Type A (spastic) – the moment you’ve glimpsed the vocal cords in your zone two stab wound, your arm starts joggling and your ears start whistling and suddenly it’s like trying to intubate in the back of a flatbed truck whizzing down a gravel road at midnight. Or Type B (flaccid) – the unresponsive infant arrives, and you lose all tone while your brain goes still and dead-white as the baby. And then there’s Type C (mixed with cognitive/axis 2 features) – you reach the bedside of the agitated patient with the deeply creepy eyes, and a single quaver in your voice betrays you and alienates your patient, so you leave the room to re-set, snapping at the nurse for it-doesn’t-matter-what on the way out. Meanwhile, you feel your grip on the department slip, slipping, sliding, until suddenly: tunnel-vision.  The rest of the department falls away, and you sit down to take care of some charting.

And this is where the problem with our usual fearless funambulism presents. We become so accustomed to fear, even to the odd intermittent surges in the fear-force, that we fail to recognize when we are in the free-fall commonly known as panic.  And, because we’ve become so good at masking our response to fear, even if we ourselves know we are scared, we fail to give off the signs that would tell someone else we are in trouble and allow them to help.

We are ashamed of our fear, of what it says about us, and most of all of what fear has made us do.  Even now, I’m scared to write down here the stupid things I’ve done while in the grip of fear.  Snapped at nurses, sure.  Just gone ahead and done something despite suboptimal conditions? Check! From removing a urethral foreign body in a teenager in a semi-public area to trying to intubate a crashing kid in an ambulance in a parking lot, resisting suggestions that we scoop him up and move him the few feet into the ED, I’ve failed in my attempts to stay sensible in the face of fear, allowing panic – masquerading as efficiency or commitment – to force my hand.  That second one died, by the way.  As did the man whose critically low calcium I didn’t notice before quickly discharging him to jail in my fearful pursuit of an unclogged ER.  There are more.  But already my fear is telling me to shut up and quit exposing myself as the rotten doctor I’m terrified that I am.

Which, I suppose, is my point with all this.  Because fear feeds on itself, and on the idiocies you commit while in its grip.  If you are in any way introspective, which based on the fact that you are reading this I assume that you are, the mistakes you make while in fear’s clutches will haunt you forever, festering and bubbling and tumescing out of sight, breeding more fear. The more calamitous fodder you give fear, the stronger it gets, and the stronger it gets, the more ravaging fear’s effects on your capacity to walk the tight-rope of our practice.

Even more difficult than admitting fear is admitting that we have two fears – we fear for our patients’ wellbeing, of course.  But when we really look in the dark crannies of our souls (in that place where we know that whatever we call it, what we are doing is deep sedation) we must admit that, perhaps even more, we fear SCREWING UP. That fear comprises concern for our patients, but also intense self-interest.  Usually, our systems are set up (and we should be deeply grateful for this) so both types of fear prod us to do the right thing for our patients. But retaining our clarity of thinking on this division allows us to consciously address the rare cases in which what is in our own self-interest is not in the best interest of the patient (Think repeat abdominal CT. Think the quick opiate prescription to avoid an argument. Think rushing a jail-bound patient out before sign-out so you can present a tidy ED and head home for a beer.)

So what to do? The first thing, I believe, is to acknowledge fear, something I’ve found remarkably difficult in the cowboy culture of EM. We acknowledge it obliquely (who hasn’t retrospectively discussed the tone – or lack thereof – of their own sphincters during a code), but when was the last time you said – or heard any other ER doc say, in the moment – “I’m scared.” I’m not advocating dwelling on your fear (at least not while on-duty), just a tip of the hat, a reminder to tare the scale.  And, once you trust your nurses and your colleagues, admit it to them as well.  Don’t dwell, just acknowledge.  You’ll burn up some of the fog surrounding your thinking, they’ll be ready to help, and you might just let them access and stabilize their own fear one day.

Then, of course, there is our balance-pole of knowledge, which well-tended and polished will consistently counter-act the eddies of fear. Don’t forget that if you don’t have a balance-pole, an umbrella might do the trick, by which I mean – grab a book, your phone, a friend – it’s so rare that there truly isn’t time to look something up, but so easy to let fear delude us into thinking we’re better off using that time elsewhere.

When you don’t have those couple of minutes, that’s when you may have to follow the famous twin-tower tight-rope artist Philippe Petit’s advice: “Wirewalker, trust your feet! Let them lead you; they know the way.”  Just don’t forget that he spent six years planning his twin towers walk, including hiring a helicopter to surveil the area, sneaking into the towers during construction, and building his own scale model of the towers to practice on.  He studied, he collaborated, he made friends with workers at the site.  You have, too.

Petit acknowledged that his performance is simple, a single path; it’s life on the ground that’s complex, and therefore hard. Due to the intricacy and monumental stakes of our own job, we will make terrible mistakes.  Deny your fears, allow their exposure to make you angry and defensive, and the winds begin to blow and the line to pitch.  Beat yourself up, hold yourself to the rigid and pristine standard we all have in our heads and you, and your patients, will suffer.  Perhaps you cannot be the doctor you wanted to be.  But ask yourself this: are you better than no doctor at all?  If the answer is yes, then you must tip your hat to fear, forgive your missteps, even the unimaginably appalling ones, then climb back up the ladder, grab your pole and set your eyes forward, and – trust your feet.

 

References / Further Reading:

-Wikipedia, https://en.wikipedia.org/wiki/Philippe_Petit, accessed 2017-03-03

-Philippe Petit, To Reach the Clouds: My High Wire Walk Between the Twin Towers. North Point Press (September 4, 2002)

EM Mindset: Tips on Becoming a Supreme Educator

Author: Benjamin H. Schnapp, MD (@schnappadap, Assistant Program Director, Assistant Professor, Department of Emergency Medicine, University of Wisconsin) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

I can’t pretend to know more about how to be a great EM doc than the amazing folks who have already written for this series – the archives are filled with endless pearls of wisdom and are well worth a look (http://www.emdocs.net/category/em-mindset/).  Educating in the midst of a busy EM shift, however, requires its own dedicated mindset to be successful.  Here are some of the things I’ve learned about teaching in EM along the way.

Every great teaching shift has a beginning, middle, and end.

I sometimes find myself at a loss as to what feedback to give residents at the end of shift; the day goes by so quickly, it’s hard to remember what points I once wanted to communicate.  This is almost always because I didn’t organize my day properly from the start.  If I ask learners at the beginning of the shift what their goals are for the day, it helps organize my interactions with them.  Rather than trying to evaluate everything they do, I can zero in on one aspect of their performance, which is easier to accomplish.  The feedback conversation at the end of shift also flows naturally – it’s easy to bring up your initial conversation and immediately have specific suggestions that you know the resident is interested in.

Bring a toolbox to work.

You wouldn’t show up to build a house without the proper set of tools for the job.  Why would you show up for your next teaching shift similarly unprepared?  All sorts of great teaching tools have been developed to help you deal with any educational quandary you might come across.  Need to work on developing a learner’s differential diagnosis?  You’ve got to know about the SPIT technique.  Don’t have time for a verbose presentation right now?  Aunt Minnie may be just the thing.  “Teaching When Time Is Limited” (http://bit.ly/2kQPs9S) is a great place to learn more about these essential skills.

Smaller is better.

It’s easy to feel that if you aren’t sitting your team down for an extensive lesson on every patient that you’re not doing much teaching on shift.  However, these extended moments for teaching can be hard to come by in the ED.  Instead of looking for big teaching opportunities that may never come, think small.  One article, pearl of wisdom or even a simple fact can have a huge impact on your learner’s future practice, and there’s no risk of distraction from extraneous information.  This goes for feedback at the end of shift too – if you’ve got an important point to get across, don’t bury it in a pile of less essential feedback.

Don’t signpost.  Billboard – in neon.

Signposting refers to the practice of telling residents that you’re about to teach them before you do.  In theory, this avoids the common problem of residents underrecognizing the educational pearls you impart throughout the shift. In practice, I find even this is often insufficient.  You need glaring, unmistakable indications of ongoing education.  Grab a giant whiteboard (@amalmattu is a fan of this one).  Stick brightly colored post-its to your computer (a la @M_Lin).  Stand up and shout (I have been known to do exactly this prior to a mini-teaching session).  Find something that meshes well with your teaching style and get credit for your great work.

Eliminate mindreading.

It is fun to teach evidence-based medicine, but the world we encounter every day in the ED is highly complex. Often, great evidence to aid us in managing our patients is lacking.  In this setting, learners can see wide variations in attending practice patterns, which can be frustrating to their learning.  Why does this elderly patient who has fallen get admitted and this one goes home?  Aid learners in developing expert-level thinking by lending them some of yours.  For particularly tricky cases, I highlight my diagnostic process out loud to my learners, including what pieces of the case I am keying in on most.  Though some may worry that verbalizing their thinking may expose a lack of solid grounding for their decisions, learning to make good choices with limited information is an essential part of the job.

Hidden teachers are everywhere.

While EM docs like to think that we have the most interesting job in the department, there is a ton of important work that’s constantly being done by nurses, pharmacists, techs, social workers, and others that can offer incredibly valuable learning experiences, especially for more junior learners.  While you shouldn’t unload your learner onto another staff member for a whole shift, helping a nurse place an IV or catheter, assisting a pharmacist with dosing medications or watching a tech do a 12-lead EKG can be great opportunities for learners to get involved and learn new skills one on one from staff that will likely be thrilled for the teaching opportunity.  Don’t be afraid to utilize your resources.

Be there.

Woody Allen once said that 80 percent of life is showing up, and in many ways, the same goes for educating in the ED.  There are a million reasons not to leave your chair on shift – the chair is warm and close to your coffee, you have charts to complete, the resident doesn’t need your help, etc.  Resist this impulse and go observe your learners at work.  You’ll be surprised what knowledge gaps you find – there are senior residents out there with poor laceration repair skills!  This is also an excellent method to uncover previously hidden communication and efficiency issues that may not come to light elsewhere.  Even the most skilled learner can benefit from your experience and perspective on how to fine-tune their approach to patients and procedures.

Silence is golden.

When learners don’t know the answer to one of your questions, it can be tempting to just give it to them rather than sit in awkward silence.  Resist this urge, and embrace the awkwardness.  Some learners may need more time to think about your question, and you won’t understand the exact nature of their deficit unless you wait.  One learner might know exactly the right answer but not be confident enough to share.  Another might misunderstand the entire concept you’re inquiring about.  The next step in your teaching is completely different for these two learners, but unless you stop and wait to hear what they have to say, you’ll never know the difference.

Be humble.

The ED is a constantly humbling place.  You make thousands of decisions per shift: the best you can hope for is only getting a few of the small ones wrong.  Occasionally though, you may find yourself humbled by a bigger error.  The resident orders a CT scan that you tell them wasn’t needed and there’s a major finding.  The patient you sent home comes back septic.  Own up to these errors.  I’ll even email the resident directly to point out what happened – if the unexpected outcome was a learning experience for you, it will also be one for the resident.  Open dialogue will go a lot further for promoting trust and a positive learning environment than futilely trying to preserve an aura of invincibility.  Similarly, don’t be afraid to ask your learners for feedback on your teaching – they may have a great tip that you’ve overlooked!

You are always teaching.

There are days when all the consultants are difficult, all the dispositions are complicated, and by the way, your electronic medical record system is going to be down for the remainder of your shift.  When catastrophes (large or small) occur, teaching is often the first thing to go – who has time to sit down with the medical student when the ED is falling apart?  It’s important to remember in times like these that you are actually doing some of the most critical teaching that you’ll ever do.  As the captain of the ship, all eyes are on you for how you’ll manage the crisis.  Bad behaviors like avoidance, blaming others, or taking frustrations out on patients will quickly establish for all of your learners that these are acceptable behaviors when circumstances get difficult.  Show them instead how you lead through tough situations – even if that’s all you teach them that day.

Ultimately, I think it’s your intrinsic interest in improving as a teacher that will get you the farthest as an educator, and if you’ve made it to the end of this post, you likely have this quality in spades!  Do you have experience with any of the above techniques?  Words of wisdom of your own?  Feel free to share in the comments.

Special thanks to Dr. Abra Fant (@DrAbracadabra) and Dr. Aaron Kraut (@akraut23md) for their assistance with this piece.

The Pros and Cons of Emergency Medicine as a specialty

Today we host some thoughts on the positives and negatives of practicing Emergency Medicine from Dr. Broders. This post contains pearls on what you should consider in EM. For more, check out this EM Mindset piece by Dr. Broders: http://www.emdocs.net/em-mindset-compton-broders-a-reflection/

Author: A. Compton Broders, MD, MMM, FACEP (Professor, UT Southwestern) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Pros

  1. Exciting and varied
  2. Time Control
  3. Pay ok
  4. Learning specialty
  5. Worthwhile work
  6. Center of healthcare
  7. Great prep for healthcare leadership

Cons

  1. Grossly abnormal time schedule.
  2. Night and holiday work
  3. Sometimes lack of system support
  4. Sometimes chaotic
  5. Frequent difficult patients

Aspects

  1. No long term patient relationships
  2. No continuity of care
  3. Varied pace of work
  4. All patients cared for without regard to ability to pay
  5. Work with a wide variety of professionals

Historical perspective:

When EM started it was disrespected; not now

Reasons people leave

  1. Night work
  2. Frustration with emergency patients

Personal traits of physicians with a long emergency career

  1. Large sense of humor
  2. Sense of whimsy about human frailties
  3. Tolerance
  4. Some degree of insensitivity to human suffering
  5. Biologic clock in center of day
  6. Intellectual curiosity
  7. Strong outside interests
  8. Good Support systems
  9. Some comfort with work messiness

Thanks for reading! Please post any thoughts you have below.

Emergency Department Tips & Tricks for Managing the Suicidal Patient

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

An adolescent male with a chief complaint of suicidal ideation presents to the emergency department (ED). The 17 year-old patient is lead to a triage room where a nurse checks his vital signs, performs an EKG, and draws blood for initial screening labs. After handing the young man a set of hospital scrubs, the nurse exits, pulling the curtain to allow for limited privacy. Minutes later, a chilling scream echoes through the halls. Personnel rush to the triage center where an attending physician is struggling to remove a disposable latex tourniquet from the, now cyanotic, patient’s neck.

Believe it or not, this is a depiction of recent events witnessed in a community ED. As you stand ready to perform your medical screen and proceed to phone a friend in psychiatry, let’s take a minute to address a few pearls in approaching the suicidal patient.

Epidemiology of Suicidal Ideation

Today more than twelve million annual emergency department visits involve a diagnosis related to mental health or substance abuse; representing nearly one in every eight ED encounters.1 Occurring at a rate of one suicide every thirteen minutes, intentional self-harm represents the leading cause of death among persons greater than 85 years of age. Among American Indians and Alaska natives ages 10-34, and in all U.S. citizens aged 15-34 years, suicide is the second leading cause of death.2 Data currently identify males as four times more likely to commit suicide than females.2 Costs associated with suicide, both medical and related to decreased work productivity, total nearly $51 billion annually.2

The Role of the Emergency Physician

This review will address patient stabilization and provide tips and tricks for use in interviewing and evaluating the suicidal patient. An in-depth discussion of toxic ingestions will be omitted as this content is addressed elsewhere:

FOAMED Resource Series Part IV: Toxicology
Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC)
http://www.emdocs.net/foamed-resource-series-part-iv-toxicology/

Stabilize the Patient

Current surveys suggest that approximately one million people in the U.S. engage in intentional self-harm behavior, and that for every death reported by suicide, approximately twelve individuals severely harm themselves.3 Of patients inflicting self-harm, nearly 650,000 are evaluated in the ED each year.4

Patients may present after a failed suicide attempt by gun-shot wound (mechanism in 59.6% of males having committed suicide4), suffering from the affects of an acute toxic ingestion (mechanism in 34.8% of females having committed suicide4), or actively bleeding from an arterial laceration (cutting, burning, and blunt trauma reported by males and females as common mechanisms of self-harm5); therefore, the emergency physician must stand ready to address the ABCs.

Transition the Patient to a Safe Environment

All patients who are hemodynamically stable upon presentation should be taken to an area of the ED that is free of all potentially dangerous medications and equipment. Patients should be searched for weapon/substances and be provided a set of scrubs or disposable clothing to discourage elopement. At no point in time should the patient be left unattended.6

 Perform an Assessment of Suicide Risk

Obtain an appropriate medical history centering on the identification of risk factors for suicide:

screen-shot-2016-11-24-at-6-52-31-pm

A few words on risk factors:

Adolescents: Adolescent patients are most likely to present with injuries secondary to self-harm (ratio of attempted to completed suicides reported as 200:110). Although parental consent is typically required for the treatment of minors (defined as age <18 in the majority of states), evaluation following a serious suicide attempt is mandated according to the Emergency Medical Treatment and Active Labor Act.6

If and when present, parents and caregivers should be questioned regarding impulsive behavior, bouts of aggression, significant family stressors, and inter-personal conflicts, as these can be subtle signs of depression.11

The elderly: Suicidal ideation is endorsed much less frequently in the elderly population,12 however, completed suicides are much more likely to occur later in life (ratio of attempted to completed suicides reported as 4:112,13). Patients >65 years of age should be questioned specifically regarding: recent death of a loved one, perceived poor health, social isolation and loneliness, uncontrolled pain, and major changes in social roles as these are frequently associated with completed suicide.12

 Current psychiatric diagnosis: When controlled for other factors, a previous history of major depressive disorder is the most significant risk factor for completed suicide in males and females.11 Patients with a history of military service should be questioned regarding post-traumatic stress disorder as these individuals are also at increased risk for suicide.11

Substance abuse: Current data identify 19-27% of all suicides as associated with alcohol.14 Specifically, individuals over the age of 18 engaging in heavy episodic drinking (having ≥ 5 alcoholic drinks in a row on one occasion) are noted to have a suicide risk 1.2 times that of their non-drinking counterparts.15 Question patients regarding alcohol consumption.11,14,15

 An assessment of thought content is particularly important in patients with a previous medical history of schizophrenia, mood disorder, bipolar disorder, and substance abuse as these conditions pre-dispose to episodes of psychosis.14 Patient reports of auditory hallucinations, persecutory delusions, or thoughts of external control or religious preoccupation require immediate hospitalization in order to prevent harm to self or others.12,14

 Patients should be questioned regarding prescription drugs (dosing/compliance/regimen changes), the use of homeopathic remedies, and the use of over-the-counter medications. This information is vital if suspecting toxic ingestion, medication withdrawal, or mood alteration secondary to changes in pharmacotherapy.

In interviewing the patient, enquire as to weapons access as this is also an independent risk factor for completed suicide.8

Perform risk stratification:

If you attended a medical school in the U.S., chances are that you’ve had some exposure to the Modified Sad Persons Score:

screen-shot-2016-11-24-at-6-55-54-pm

Originally developed by Hockberger and Rothstein at the Harbor-UCLA Medical Center in 1988, this scoring tool was created to predict the need for hospitalization in individuals at risk for suicide. After analysis of 119 patients, Hockberger and Rothsetin identified a score ≥ 6 as having a sensitivity of 94% and a specificity of 71% for predicting the need for psychiatry directed hospitalization (P<0.001).14 While an excellent reminder of suicide risk factors, the authors’ score is limited in that it was designed to assess the decision-making of behavior of psychiatry personnel at one institution.

The Manchester Self-Harm Rule was published by Cooper et al.17 in 2006 as a mechanism to determine the risk of repeat self-harm or suicide in patients presenting to the ED with the chief complaint of self-injury. Demographic and clinical information from 9,086 patients presenting to 5 emergency departments in Manchester and Salford, England (2001-2007) were utilized to identify the following risk factors:

screen-shot-2016-11-24-at-6-57-06-pm

The Manchester Self-Harm Rule demonstrated 94% sensitivity in the detection of individuals who would perform repeated self-harm or suicide within six months following the initial ED encounter (patients who possessed one or more risk factors).17 Data utilized in developing the Manchester Self-Harm Rule was collected from an urban population with high rates of benzodiazepine use and abuse, thus limiting its generalizability.17 Ultimately, clinical judgement in the evaluation of the suicidal patient is paramount.

Performance of the Physical Exam (Secondary Examination in the Hemodynamically Unstable Patient)

Elements of the physical exam include an assessment of:

  • The patient’s general appearance (emotional status, thought content, and affect).
  • A complete physical examination of the head, body, and extremities with documentation of all visible injuries.

Actively search for signs and symptoms of acute ingestions, toxidromes, and withdrawal symptoms: diaphoresis, hyperthermia, hypopnea, or bradypnea, pinpoint or dilated pupils, hyper or hyporeflexia, clonus, tremor, or altered mental status.18

  • Sympathomimetic toxidrome: agitation, delirium, hypertension, hyperthermia, nausea, and muscle rigidity.
  • Anticholinergic toxidrome: mydriasis, urinary retention, tachycardia and hyperthermia.
  • Serotonin syndrome: altered mental status, autonomic instability, myoclonus, and tremor.
  • Neuroleptic malignant syndrome: lead pipe rigidity, hyperthermia, altered mental status.
  • Monoamine oxidase inhibitor (MAOI) toxicity: severe hyperthermia, nausea, emesis, and cardiovascular collapse. Excessive ingestion of tyramine containing food stuffs during MAOI therapy may result in hypertensive crisis.
  • Patients experiencing benzodiazepine, opiod, and alcohol withdrawal may present with agitation, hypertension, tachycardia, and GI upset.

Primary interventions should address airway, breathing and circulation. Benzodiazepines are the treatment of choice for agitation, anticholinergic toxicity, sympathomimetic toxicity, and serotonin syndrome. Dopamine agonists have been demonstrated to improve symptoms in neuroleptic malignant syndrome. Provide fluid resuscitation in the setting of seizure and muscular rigidity in order to avoid complications secondary to rhabdomyolysis.18

Evaluate for signs and symptoms of medical conditions, and their sequelae, that are commonly associated with psychiatric symptoms:

  • Hypoglycemia (perform a bedside blood glucose assessment)
  • Thyroid pathology (thyroid storm or myxedema coma)
  • Cushing’s
  • CVA/TIA
  • Intracranial trauma
  • Infectious etiologies: HIV, syphilis, meningitis/encephalitis
  • Neoplasm (intracranial mass vs. hypercalcemia secondary to metastasis)
  • Degenerative neurologic diseases (Alzheimer’s, Parkinson’s, Creutzfeld-Jacob, Multiple Sclerosis)19

Notes on the agitated patient: if the patient presents a risk to self or others, the utilization of chemical or mechanical restraints should be entertained, bearing in mind that this may worsen hyperthermia and rhabdomyolysis. See Dr. Lulla’s and Singh’s The Art of the ED Takedown for a quick refresher on these interventions: http://www.emdocs.net/the-art-of-the-ed-takedown/

 Pertinent Studies

Once a thorough history and physical examination are completed, clinical decision-making should be utilized to assess the need for advanced imaging and adjunct studies.

Imaging: A non-contrasted CT head à rule out intracranial mass/abscess, intracranial hemorrhage, hemorrhagic CVA, etc. Consideration should be made for additional imaging as required (CVA: CTA head/neck vs. MRI/MRA, etc.).

EKG: An EKG may be diagnostic in the hemodynamically unstable patient. Sodium channel blockade (tricyclic anti-depressant therapy) often manifests as a rightward axis in the terminal 40-msec of the QRS complex (terminal R wave in aVR).20

Currently there are no data-driven consensus recommendations regarding the appropriateness of routine laboratory screening tests in patients with suicidal ideation. As previously mentioned, the history and physical exam should be utilized to direct evaluation for an underlying organic etiology of depression and suicidal ideation. Studies to consider include21:

  • CBC
  • CMP
  • TSH, FT4
  • RPR/VDRL, FTA-ABS
  • HIV
  • Serum ETOH
  • Serum salicylates
  • Serum acetaminophen

The use of urine drug screens (UDS) in the evaluation of suicidal patients is controversial, as numerous studies have demonstrated the results of these screens as having minimal impact on patient care. Given these findings, the American College of Emergency Physicians currently recommends against the routine use of UDSs in the suicidal population.22

Disposition

After performance of patient stabilization, attainment of a history and physical, and assessment of imaging/laboratory studies as appropriate, medical clearance may be given, and consultation placed for specialist evaluation and treatment.

If the patient appears to be a risk to him/herself or others, or is gravely disabled (unable to provide for his/her basic needs), involuntary psychiatric detention should be pursued. Regulations regarding involuntary psychiatric holds are state specific, therefore the emergency physician must be apprised of local policies and procedures.8 Obtaining collateral information from family and friends will often facilitate this intervention.19

Contracts for safety: While some physicians may elect to create a contract for safety, allowing outpatient evaluation and treatment, this is not advised for the emergency physician. Contracts for safety do not substitute for adequate documentation regarding the risk of suicide, or free the physician of liability in cases of subsequent self-harm and suicide.8

Key Pearls

  • Stabilize as appropriate => a number of patients will present after performing self-harm
  • If the patient is hemodynamically unstable, consider an EKG to evaluate for sodium channel blockade (TCA overdose)
    • Quickly evaluate for signs/symptoms of toxic ingestions
  • In the stable patient, perform an H&P focusing on risk factors for suicide
    • Question patients regarding substance abuse (specifically alcohol)
    • Question regarding access to weapons
    • Use friends/family to corroborate stories
  • During the physical examination, evaluate for findings consistent with toxidromes or organic pathology
  • After seeking out organic etiologies of suicidal ideation, medically clear the patient and consult a specialist
  • Be familiar with state laws regarding emergency detention
  • Avoid the use of safety contracts in the emergency setting

 References / Further Reading

  1. Owens P, Mutter R, Stocks C. Mental health substance abuse-related emergency department visits among adults 2007. Statistical Brief #92. Agency for Healthcare Research and Quality. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf
  2. Centers for Disease Control and Prevention. Suicide: Facts at a glance. Available from: https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
  3. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). National Center for Injury Prevention and Control. Available from: http://www.cdc.gov/injury/wisqars/index.html
  4. Chang B, Gitlin D, Patel R. The depressed patient and suicidal patient in the emergency department: Evidence-based management and treatment strategies. Emergency Medicine Practice. 2011; 11(9):1-24.
  5. Kerr P, Muehlenkamp J, Turner J. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-259.
  6. Kennedy S, Baraff L, Suddath R, Asarnow J. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004; 43:452-462.
  7. Mendelson WB, Rich CL. Sedatives and suicide: The San Diego study. Acta Psychiatr Scan 1993;88:337–41.
  8. Ronquillo L, Minassian A, Vilke G, Wilson M. Literature-based recommendations for suicide assessment in the emergency department: a review. J Emerg Med. 2012; 43(5):836-842.
  9. American Foundation for Suicide Prevention. Suicide Statistics. 2016. Available from: https://afsp.org/about-suicide/suicide-statistics/
  10. Tuzun B, Polat O, Vatansever S, Elmas I. Questioning the psychosocio-cultural factors that contribute to the cases of suicide attempts: an investigation. Forensic Sci Int 2000;113:297–301.
  11. Schwab J, Warheit G, Holzer C. Suicidal ideation and behavior in a general population. Diseases of the Nervous System. 1972;33(11):745–748.
  12. Mitchell A, Garand L, Dean D, Panzak G, Taylor M. Suicide assessment in hospital emergency departments: Implications for patient satisfaction and compliance. Top Emerg Med. 2005; 27(4):302-312.
  13. Parkin D, Stengel E. Incidence of suicidal attempts in an urban community. British Medical Journal. 1965;2(54):133–138.
  14. Canapary D, Bongar B, Cleary K. Assessing risk for completed suicide in patients with alcohol dependence: Clinicians’ views of clinical factors. Professional Psychology: Research and Practice. 2002;33(5):464–469.
  15. Asteline R, Schilling E, James A, Glanovsky J, Jacobs D. Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program. J Am Acad Child Adolesc Psychiatry. 2009; 48(3):262-270.
  16. Hockberger RS, Rothstein RJ. Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score. J Emerg Med. 1988;6:99–107.
  17. Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K. A clinical tool for assessing risk after self-harm. Ann Emerg Med 2006;48:459–66.
  18. Zosel A. General Approach to the Poisoned Patient. In Emergency Medicine: Diagnosis and Management. 7th ed. Boca Raton: CRC Press, 2016: 292-298.e1.
  19. Knoll, J. The Psychiatric ER Survival Guide. 2016. Upstate Medical University. Available from: http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/psych-survival2.pdf
  20. Niemann J, Bessen H, Rothstein R, et al. Electrocardiographic criteria for tricyclic antidepressant cardiotoxicity. Am J Cardiol. 1986;57(13):1154-1159
  21. Russinoff I, Clark M. Suicidal Patients: Assessing and Managing Patients Presenting with Suicidal Attempts or Ideation. 2004. Available from: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=97
  22. Lukens T, Wolf S, Edlow J, Shahabuddin S, Allen M, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006; 47(1):79-99.

Geriatric Trauma and Medical Illness: Pearls and Pitfalls

Authors: Matthew R Levine, MD (Assistant Professor and Director of Trauma Services, Department of Emergency Medicine, Northwestern Memorial Hospital, Chicago, IL) and Lora Alkhawam, MD (Attending Physician, Duke Regional Hospital, Department of Emergency Medicine, Durham, NC) // Edited by: Erica Simon, DO, MHA (@E_M_Simon) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

An 85 year-old male is brought in by EMS status post MVC. He is confused and unable to detail the events surrounding his accident. When questioned, he has no recollection of his PMHx, but repeatedly states that he is in pain secondary to his c-collar and backboard. Vitals: HR 70 and irregular, BP 110/65, RR 16, O2 sat 94% on room air. Primary and secondary surveys are remarkable only for scant wheezing upon pulmonary auscultation. GCS is 14 without focal neurologic deficits. As you contemplate the next steps in your patient evaluation, you scan your knowledge bank: What critical diagnoses should you be considering? Let’s discuss some pearls and pitfalls in addressing the geriatric trauma patient.

 

Importance

According to 2010 US Census data, adults > 65 years of age account for 14% of the current U.S. population.1,2 It is estimated that nearly one in five Americans will be elderly by the year 2050.1,2 Why is this relevant to the practice of emergency medicine? Approximately 1 million persons aged 65 and older are affected by trauma each year.3  In fact, trauma in the elderly accounts for $12 billion in annual personal and institutional medical expenditures, and $25 billion in total annual healthcare expenditures.4 While elderly patients comprise a small percentage of total major trauma patients (8-12%) presenting to emergency care centers, they represent a disproportionate percentage of trauma fatalities and costs (15-30%).4

To date, numerous studies have demonstrated mortality related to trauma as increasing with advancing patient age.5-7 In fact, the Major Trauma Outcome Study published in 1989 (n = 3,833 > age 65 and 42,944 < age 65) demonstrated mortality as rising sharply between the ages of 45-55 and doubling by age 75.5 This pattern occurred at all Injury Severity Scores (ISS), mechanisms, and body regions.5

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Representation of Trauma Mortality Data5

Today, we also know that advancing age is an independent risk factor for morbidity and mortality, despite lesser severity of injuries.1,2,5 However, while age has value in mortality projections for geriatric trauma patients presenting to the ED, literature suggests favorable functional outcomes for those who survive to hospital discharge.8 Therefore, age alone is not a criteria to deny or limit care in the elderly.9

 

Objectives

 This review will highlight important differences in elderly trauma patients with respect to:

  • Triage
  • Pathophysiology in the Elderly
  • Mechanisms and Patterns of Injury
  • Trauma Bay Approach
  • Special Considerations

There will be many citations throughout, but please keep in mind the limitations of research in geriatric trauma:8

  • Few prospective randomized controlled trials
  • No widely accepted age cut-off (“elderly” used to characterize patients ages 45-80)6
  • Lack of a uniform definition of an elderly trauma patient
  • Limited current studies (majority based in the 1980s-1990s)

 

Triage of the Elderly Trauma Patient

In its statement regarding trauma in the elderly, the CDC notes: “under triage of the older adult population is a substantial problem.”10 Under triage is defined as a failure to transport a trauma patient to a state-designated trauma center.10 Why is this important? Current studies (Zafar et al. and Maxwell et. al, 2015) have identified a significant mortality benefit for elderly patients presenting to trauma centers having had repeat exposure to geriatric trauma.11,12 Zafar et al. reported elderly patients as 34% less likely to die in these trauma centers.11 While it is true that level 1 trauma centers traditionally have longer lengths of stay and higher total costs of care, a large percentage of elderly trauma patients survive discharge from these facilities.11,12 Elderly patients with multiple injuries benefit from trauma center care.11,12 The difficulty here is that standard adult EMS triage guidelines provide poor sensitivity for detecting older adults that require trauma center care.13 The under triage rate is reported as 50%14,15 in patients older than 65, versus 17.8% for those under 65.14 Given this data, several experts have concluded that an age threshold should be established which mandates triage to a trauma center (various age ranges (55-70) have been recommended).6,9,16,17,18

What difficulties are encountered in identifying trauma severity in the elderly population? Potential explanations for under triage of elderly trauma patients are: significant injury secondary to low energy mechanisms, and altered physiologic response to injury with aging.

  • The CDC recommends direct transport to a trauma center for any trauma patient age >65 with SBP <11010
    • What affect does this have on triage of the elderly population? One that is substantial:
      • Substituting SBP < 110 instead of SBP < 90 for patients older than 65 reduced under triage by 4.4%, while only increasing over triage by 4.3%.19

Once an elderly patient arrives at a trauma center, trauma team activation occurs significantly less often for elderly patients (14% vs 29%) despite a similar percentage of severe injuries (defined as ISS>15).l

  • The Eastern Association for the Surgery of Trauma (EAST) recommends a lower threshold for trauma team activation for patients 65 and older evaluated at trauma centers (level 3 evidence).20
    • Some trauma centers use age as mandatory criteria for trauma team activation. This is supported by data that 63% of elderly trauma patients with ISS > 15 had no standard physiologic activation criteria.20

Clinical implications: Have a low threshold for recommending EMS transport of elderly trauma patients to a designated trauma center, especially for patients with SBP < 110. Have a low threshold for activating the trauma team for elderly trauma patients.

 

Pathophysiology Concerns in the Elderly

No other population is more susceptible to serious injury secondary to low-energy mechanisms (particularly falls) than the elderly. The elderly are less able to compensate for physiologic stresses occurring during injury, and are more likely to suffer complications during treatment and recovery. Key reasons for this are:

  • Less physiologic reserve
  • Occult shock/misleading picture of stability
  • Comorbid illnesses (See Figure below)

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Comorbid Illnesses Contributing to Morbidity and Mortality in the Elderly

It is important to note that in elderly patients, profound shock may be present even in the setting of “normal” vital signs.  Pharmaceutical therapy in the elderly (beta blockers and calcium channel blockers) may prevent typical tachycardic responses in shock states.  Also significant, aging myocardium exhibits decreased sensitivity to endogenous catecholamines.

Blood pressures considered normal in young patients may represent hypotension when compared to baseline BPs in an elderly patient. A landmark article by Scalea et al. assessing early invasive (PA catheter) monitoring in elderly trauma patients demonstrated that the majority of trauma patients experienced profound perfusion deficits despite “normal” vital signs.19 In fact, a HR>90 and SBP<110 have been correlated with increased mortality in the elderly trauma population.19,21 What does this mean for the EM provider? The window to intervene may be narrow; delayed recognition of shock may postpone life-sustaining resuscitation.

What about additional markers of perfusion?

Multiple studies have demonstrated that elevated lactate levels (>2) or abnormal base deficit (<-6) are associated with major injury and mortality in trauma patients.23-25 One such study, performed in 1987, identified a venous lactate > 2.5 as a marker of occult hypoperfusion in 20% of the included geriatric patients.26 Lactate levels or ABG base deficit should be used as an adjunct to vital signs for early identification of perfusion deficits in elderly trauma patients.

Clinical implications: Avoid being falsely reassured by normal vital signs in elderly trauma patients. Use lactate levels or ABG with base deficit as adjuncts to vital signs to detect occult shock and guide resuscitation in unclear cases. Also use ECGs as an adjunct to detect silent ischemia as a response to the physiologic stress of trauma. Have a low threshold for admitting elderly trauma patients to an ICU.

 

Mechanisms and Patterns of Injury

Which mechanisms and patterns of injury are more concerning in the elderly? They all are.

More specifically, falls from ground level, head trauma, chest wall injuries, pedestrian struck by vehicle, and cervical spine injuries have a disproportionate burden on elderly patients.

Screen Shot 2016-08-20 at 1.51.54 PM

Falls are the most frequent cause of injury in patients > 65 years of age, and are the most common fatal accident in patients > 80 years of age.27 More than one third of elderly patients presenting to the ED post fall return to the ED, or die within one year of initial evaluation.28 Same level falls must not be minimized – they are ten times more likely to cause death in an elderly vs. non-elderly patient (25% vs 2.5%).29 Even falls that seem purely mechanical can be a sign of occult illness. It is imperative that emergency physicians perform a complete H&P for all elderly patients having experienced a fall for:

  • Sudden disturbances in cardiovascular/neurologic function
  • New/progression of underlying conditions or emerging infection
  • Intoxicants/medication effects
  • Environmental safety
  • Impact of injury on functional status/ability to care for self

Why are falls so devastating in the elderly population?

Age-related atrophy of the brain leads to increased potential space and shearing forces on the intracranial bridging veins when exposed to trauma. The risk of intracranial bleeding is also markedly increased with medications commonly prescribed to the elderly (anticoagulants and anti-platelets).30,31 Keep in mind that older patients are excluded from studies that attempt to identify populations in which imaging is low yield = IMAGE the elderly.

 Outside of head trauma, are there any other areas for EM docs to be on the lookout?

Even “minor” chest injuries impair the elderly. Thoracic cage trauma is poorly tolerated secondary to decreased compliance, loss of alveolar surface area, impaired lung defenses, and increased pulmonary bacterial colonization with aging. A rigid C-collar and backboard can further impair chest wall expansion. Elderly patients with rib fractures are at increased risk for pneumonia (31% vs. 17% with 16% increase per rib fractured), pulmonary contusion, and delayed hemothorax.32 Mortality also increases 19% per rib fractured.32

 The elderly spine is vulnerable to fracture from minor mechanisms due to conditions such as cervical stenosis, osteoporosis, and degenerative, rheumatoid, and osteoarthritis.33 High cervical fractures (type 2 odontoid being the most common), and central cord syndromes are also more frequent in the elderly.34

Pedestrian struck by a vehicle is perhaps the most devastating mechanism of injury to disproportionately affect this population. Patients age > 65 account for 22% of pedestrian vs. MVC deaths.33 Current statistics report 46% of these accidents as occurring in crosswalks.33 Factors that predispose the elderly to increased severity of injury include decreased ability to raise or turn the head due to cervical arthropathy, and reduced speed and agility (crosswalk timers often allow for a pedestrian speed of 4 ft/sec).33

Clinical implications: Maintain a heightened suspicion for significant injury (especially intracranial and C-spine pathology) even from ground level falls. Assess elderly patients for medical impairments that may have precipitated the fall. Be liberal with CT scanning for elderly head and neck trauma, and always inquire regarding the use of anticoagulant and antiplatelet medications. Ensure adequate analgesia and oxygenation for chest wall injuries. Remove the collar and backboard as early as safely possible. Maintain a low threshold for admitting elderly patients with rib fractures.

 

Special Considerations

 ABCs in the Elderly

  • A – Early airway control. Edentulous patients may be difficult to bag; remove dentures for intubation.
  • B – Avoid respiratory decompensation by use of O2; analgesia for chest injuries; suction/pulmonary toilet; clear the C-spine, and remove the backboard as early as possible to prevent respiratory impairment.
  • C – Early transfusion to minimize fluid overload from crystalloids. Recognizing that “normal” BP may be relative hypotension for an elderly patient. Question patients regarding anticoagulant use and consider reversal early in the course.
  • D – Liberal use of head and C-spine CT; GCS is not a sensitive indicator in the elderly trauma patient.
  • E – Assess for signs of comorbidities that may not have been reported (i.e. surgical scars, pacemakers, medications or med lists in patient belongings, medical alert tags, bruising from anticoagulants).

Elder Abuse

No report on elderly trauma is complete without mention of elder abuse. Elder abuse can be very difficult to detect for several reasons:

  • Patient reluctance to identify a loved one
  • Patient dependence on the abuser
  • Perceived frailty limiting the patient from feeling empowered in seeking help
  • Patient mental or memory impairment limits the history
  • Abuse in the form of neglect can mimic cachexia from comorbidities

Clinical implications: When the scenario has stabilized, assess the patient’s social situation. Be wary of wounds or injuries that are suspicious for abuse or do not match the reported mechanism of injury. And of course, ask the patient, preferably in private!

A Quick Word on Anticoagulants

Anticoagulant use is far more prevalent in the elderly population. An increasing portion of the elderly population are being prescribed novel oral anticoagulants, which are not as readily reversible as warfarin. An elderly trauma patient should be questioned regarding anticoagulants ASAP. An irregular heartbeat may be a clue to chronic atrial fibrillation and anticoagulant use. Know your institution’s reversal protocol for the novel anticoagulants. If your institution does not have a protocol, then have a plan in mind. Know which prothrombin complex concentrates are available to you. Know if Praxbind is stored by your pharmacy.

Back to the Case

The patient in the initial case presentation may have been exhibiting his normal baseline mental status or could have been confused secondary to the emotional distress pertaining to the accident, but the provider must assume the confusion secondary to intracranial bleeding until proven otherwise. The patient’s irregular heart rate should alert the clinician to the possibility of aspirin or anticoagulant use, necessitating a plan for reversal should it be needed. In terms of the rest of the vital signs: the patient’s “normal” blood pressure may actually represent relative hypotension. The borderline hypoxia (and wheezing discovered on exam) is likely related to lung injury, aspiration, or an underlying comorbidity (i.e. COPD or CHF). This should serve as a warning – the patient is high risk for respiratory decompensation from chest injury and impaired chest wall motion from the C-collar and backboard. The backboard should be removed as soon as possible, pain from the chest injury treated as applicable, and supplemental oxygen employed. Suction may be considered as an adjunct. If and when the C-spine is cleared, the patient should be placed in an upright position to facilitate gas exchange and decrease work of breathing. The patient may have critical injuries and blood loss despite minimal symptoms so a lactate or ABG for base deficit should be sent. Imaging to rule out internal injuries is a must. Initial diagnostic work-up and resuscitation should be aggressive until the patient’s prognosis and wishes are clear. Volume resuscitation should be minimized, with blood products being the fluid of choice. The clinician should have a low threshold for trauma team activation vs. consultation and admission.

 

Summary

  • Resuscitation of the elderly trauma patient must be thoughtful but aggressive:
    • Heighten awareness that with age, signs and symptoms may be minimal, and that the outcome is often initially unclear, and commonly, but not necessarily poor.
    • Up to 85% of elderly trauma survivors return to baseline or independent function.9
      • This justifies initial aggressive approach which can be reassessed later when patient/family wishes and prognosis becomes increasingly clear.9
    • Less physiologic reserve leaves little time for delays in diagnosis and under- or over- resuscitation.
    • Blood is the fluid of choice.
    • The principles of diagnosis and management in trauma are the same regardless of age, but the incidence of physiologic changes and disease states mandates a different overall approach.
    • You may be the only one in the room who knows how sick the patient really is.

 

References / Further Reading

  1. Hashmi A, Ibrahim-Zada I, Rhee P et al. Predictors of mortality in geriatric trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76:894-901.
  2. Vincent GK, Velkoff VA, U.S. Census Bureau. The next four decades the older population in the United States: 2010 to 2050. Population estimates and projections P25-1138. Washington, DC: U.S. Dept. of Commerce, Economics and Statistics Administration, U.S. Census Bureau; 2010. Available from http://purl.access.gpo.gov/GPO/LPS126596.
  3. CDC National Center for Health Statistics (NCHS), National Vital Statistics System. http://www.cdc.gov/nchs/nvss.htm.
  4. CDC Data and Statistics (WISQARSTM): Cost of Injury Reports Data Source: NCHS Vital Statistics System for Numbers of Deaths. http://wisqars.cdc.gov/8080/costT/.
  5. Champion HR, Copes WS, Buyer D et al. Major trauma in geriatric patients. Am J Public Health. 1989;79:1278-1282.
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EM Mindset – Louis Ling – Mistakes, Teaching, Connecting

Author: Louis J. Ling, MD (Senior Vice President for Hospital-based Accreditation, ACGME; Professor of Emergency Medicine and Pharmacy, University of Minnesota Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

When I work in the ED, I have to get in the right frame of mind; to psych myself up for the busy, hectic, and chaotic environment that I have grown to love. For the first few years of practice, I dreaded going to work; afraid I was going to miss something or make a mistake.  After two years as an attending, I realized that with the number of decisions that occur during every shift, mistakes and errors were inevitable.  I gave myself permission to make mistakes, but to make them safe mistakes when possible and to learn from my mistakes.  (Safe mistake does not mean overtreatment.)  That is my first mindset that I take to work every shift.

My second mindset is to teach and supervise while not getting in the way of the learners.  Most teachers are so busy telling their learners what to do, they never have a chance to learn; they only regurgitate what they were told.  I now see my role as primarily the hint generator for the “Pit Boss”.  For that to make sense, let me explain the Hennepin layout.

There are three major team centers, each with approximately 15 rooms, staffed with two to three PMPs, primary medical providers and a Pit boss and a faculty.  The Primary medical providers can be PAs, G1 residents of both EM and off service and junior EM and IM residents.  They are the primary contacts for the patients, nurses, and consultants and responsible for the charting. This team is supervised by a Pit boss, a senior EM or EM/IM resident, who also sees every patient but does no charting, except for patients seen with a medical student.  The goal is to have pit bosses make as many decisions as possible without the burden of charting (a dream job).

When I see patients, I will ask the pit boss questions as to the differential and the plan and why or why not certain tests were ordered.  The patient does not have to be managed exactly how I would if the pit boss has reasonable answers that justify their decisions, however, if pit bosses are shot gunning or missing key tests, or generally in need of advice, the management can change.  One of the challenges of being a resident is trying to guess how each particular faculty would manage each patient.  My goal is to let the pit boss manage the patient independently, while avoiding errors, not to manage the patient exactly the way that I would.

I prefer to see patients along with a resident. (I am told this is rare for faculty to observe) This is easiest at the start of each shift especially when the patients and residents are all new, or when a patient is brought in by ambulance or roomed and freshly seen by a resident. When I listen to the history, I assess how the questions flow in a logical order where the resident is trying to raise the suspicion of or to narrow the differential or to rule out possible maladies.   It is common for novices to ask from a checklist without knowing the significance of each question.  Watching the exam is instructive and residents often listen to the heart and lungs, to meet my expectation. I frequently give permission to them to skip the automatic response and simply focus on the problem area but to always examine something (for the patient’s expectation, not mine).  It is common that problem specific exams are incomplete or improperly done, again from a checklist and not to elicit information to rule in or rule out specific conditions.  Examples include joint exams, abdominal and back exams.  When we leave the room, I try to give one positive observation that they should continue and one suggestion on how to improve.  If I am commenting on the exam, I might repeat certain portions to demonstrate and to have them repeat it.  Of course, seeing patients with PMPs is inefficient and I know I will fall behind so when that happens, I resort to cruising the rest of the rooms and seeing patients quickly until I catch up.  Seeing patients with a pit boss can be efficient since they are usually quick and much more focused and this is a good way to develop a plan with the patient present that the pit boss can share with the nurses and the PMPs. We often will discuss the possible dispositions at the same time.  Because I try to actively be involved, I typically get way behind on my charting.  I write short notes emphasizing the thought process and keep current on the patients who are admitted.  For patients who are discharged, I save the charting for after my shift.  Thank goodness for CITRIX.

The Pit Boss also has primary responsibility for all resuscitation and unstable patients in the stabilization room.  (The hope for all pit bosses is to spend the day in the stab room instead of seeing patients with me.)  During those times, I take over the Pit boss role and will manage the patients directly with the PMPs.  Some PMPs are nervous about approaching me directly so I usually ask the PMPs how I can help or how their plan is progressing.  When I see patients as a PMP myself, I have learned to pick the quick and straightforward ones and move them along to decompress the area.  I discovered that when I pick up complicated patients, that despite my best of intentions, I often get distracted from them and their time in the ED is longer than if they had a different PMP.

When I picked emergency medicine as a specialty in 1979, the year emergency medicine became a specialty, I had thought the reward would be saving lives and doing dramatic procedures and never having to provide chronic care.  I now know that those moments are indeed rewarding but much less often than I had imagined.  The surprise diagnosis, solving the puzzle, and the well done procedure is still fun but the day to day reward is connecting with patients as human beings, providing a little comfort and caring, some reassurance and education.  That is a wonderful mindset to have.

When I started working for the ACGME several years ago, I had considered seeing patients in Chicago but realized that I would never become facile with the System-based practice.  The EMR would be awkward and I would be a drag and hindrance to a resident.   I only work one shift a month (and I skip July), so I have tried to minimize my system-based errors by working in the ED that I have spent 30 years, where I understand the culture, I still know the nurses and the consultants, the code to the bathroom and EPIC knows my password.  I always work in the same team center on Saturday and there are always two other faculty present in the ED.

I no longer manage resuscitations.  When I did, I still saw my role as giving hints and whispering in the Pit boss’ ear, but letting them manage the care and direct the traffic.  My other role was to keep the attending surgeon or consultant out of the way when they became meddlesome.  While I miss those cases, it was unfair to take that experience from the full-time faculty, and to care for the sickest of patients when I am no longer at the top of my game.

I often wonder when my clinical skills might become so sclerotic that I should quit clinical care altogether.  When I work with the Pit bosses, senior residents a few months away from independent practice, I realize I may not be smarter than they are but I am still much trickier.  Although I am not as fast and efficient as I once was, I am better than a new graduate.  I have to be extra careful when it comes to up-to-date and new treatment but the essence of connecting with and caring for patients is still there.  I have to ask more questions and rely on others for bedside ultrasound.

So there it is; my mindset of going to do a shift includes 1) realizing that I am going to make mistakes but to try and make them safe mistakes, 2) teaching while staying out of the way of learners’ learning, and 3) remembering to connect with human beings during their time of need.