Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Paralytic or Sedative First for RSI?

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There was no statistically or clinically important difference in time from drug push to tube placement for neuromuscular (NM) blocker first followed by the sedative or vice versa.

Why does this matter?
Some push a sedative first then NM blocker; some do the opposite. Does it matter?

How bad could conscious paralysis be anyway?
This was a secondary analysis of a prior RCT comparing first pass success with bougie or stylet. In that study, drug order was not specified. They compared the total apnea time (first drug push to tube placement) for all patients intubated on the first attempt in a total of 562 patients: 153 sedative first; 409 NM blocker first. Pushing the NM blocker first resulted in 6 seconds shorter apnea time, with a 95%CI 0 to 11 seconds. They concluded that either drug first is acceptable.

The authors state, “apart from the theoretical, albeit unlikely, concern of awareness of neuromuscular blockade, it is difficult to think of a compelling reason to administer the sedative agent before the neuromuscular blocking agent.” Now we are into the realm of opinion, but I could not disagree more. Maybe it’s just me, but potentially being conscious while paralyzed seems pretty “compelling.” In view of this study’s finding, with no statistically or clinically important difference in time to tube placement, I can’t justify pushing a paralytic first.

Drug Order in Rapid Sequence Intubation. Acad Emerg Med. 2019 Mar 4. doi: 10.1111/acem.13723. [Epub ahead of print]

#2: What Defines Pediatric Hypotension?

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The Pediatric Advanced Life Support (PALS)/Advanced Trauma Life Support (ATLS) formula to define hypotension in children (i.e. 5th percentile SBP) seems to be a good compromise between German and U.S. population norms for children. The formula is: Low SBP = <70 + 2(age in years).

Why does this matter?

  • Recognize: You have to spot an abnormal pediatric BP when you see one.
  • Repeat: Any abnormal BP in a child must be repeated and confirmed as not spurious.
  • Recheck: Intervene and recheck to see if it is improving.
  • Record: Document you saw and addressed the abnormal BP and what the response was.

Defining hypotension is not as easy as it looks. If the SBP target is set too low, we may undertriage; too high and we will have excess false positives. What is the right standard?

It depends…
There was a lack of agreement among differing population-based norms for pediatric BP on how to define hypotension, that is <5th percentile. A German database, KiGGS was on average 7mm higher than US population BP norms. KiGGs 5th percentile could be calculated in children age 3-9 years with the formula: 82 + age = SBP, though this did not hold for ages 10-17 years. PALS and ATLS use the formula to define hypotension of: <70 + 2(age in years) = SBP. This PALS/ATLS definition fell between the German and US population norms for the 5th percentile and seemed to split the difference. Keep in mind, this PALS/ATLS formula should only be used in children ages 1-10 years. The authors express concern that the 90mm definition of hypotension for children ≥10years may lead to undertriage of adolescents, according to the 5th percentile German and U.S. norms. I think this is correct; see figure (SBP plateaus for girls at around age 13).

#3: NEJM Brilliance – The Not My Problem Problem

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This editorial helps us understand how to avoid the bystander effect in medicine and has direct applicability for the ED.

Why does this matter?
Fragmented care during hospitalization and ultra-specialization may lead to patients feeling as if no one is in charge, directing their overall care.  What can we do about this in the ED?

Teamwork makes the dream work…but someone has to lead
The author describes a common scenario: the primary medicine team defers to GI; GI defers to interventional radiology (IR); IR defers to the primary team, and nothing is happening for the patient.  A version of this happens many times a day in the ED.  Often it’s hard for a physician or team to take ownership, admit a patient, or see a consult when they think another service might be better (and they could avoid driving in to see the patient).  In the editorial, a new gastroenterologist came on service midway through the patient’s stay and said, “I walked into that room, saw the distress of the patient and her family, and realized the buck was going to stop with me.”  That is powerful.  The “bystander effect” or “diffusion of responsibility” leads us to think someone else will take care of the problem.  Hence, this editorial’s title – The Not My Problem Problem.  We may also slide into a deadly “group-think” and end up paralyzed with inaction.  The author noted, “failure of other people to act serves to support interpretations or construals that are consistent with nonintervention.”  Cardiology didn’t think they needed to go to the cath lab; so, these iffy ECG changes I think I’m seeing must be OK, right?  Wrong.

Sometimes inaction is the result of our own insecurity.  The author articulated her feelings of self doubt by saying, “What could I possibly add, I often wonder, when so many experts have been involved?”  This is followed by my favorite quote from this article.  Dr. Rosenbaum notes, “There may be little distance between the paralysis of inadequacy and the mobilizing force of humility.”  In this case scenario, the new GI attending saw the patient’s suffering and determined she would take action, not because she was “better” than the physicians who had come before, but because the family needed someone to take charge of the case.  She painstakingly got all the images from the referring facility and sat waiting for a couple hours in radiology until she could get the attention of the IR attending between procedures.  This was very time consuming; some would even call it “scut work.”  But this Harvard GI attending didn’t see it that way.  She called it, “the mechanics of doctoring,” and emphasized the importance of relationship building with other physicians to get the job done for the patient.

So, why do we fail to help at times?  Is it a character issue?  Dr. Rosenbaum related a social experiment among seminary students to see if they would stop and help a staged homeless man in apparent distress, a Good Samaritan experiment.  The biggest predictor of whether or not the students would stop was perceived time pressure.  Those in a hurry were least likely to stop.  When we say, “The buck stops with me,” it’s going to take a while.

So, how does this apply to the ED?

  • Go see the patient.  Whether it’s a patient you got in sign out, someone already admitted, or a new patient with a huge pile of records from Outside General Hospital – see the patient.  It’s impossible to be a bystander when you’re actively involved.
  • Cut through “bystander effect” fog.  When you have dueling consultants or admitting teams, and each one says over the phone, “It’s not my problem,” ask them to come see the patient.  Things change at the bedside.  It humanizes the patient and personalizes the suffering.  If they won’t or can’t come to the bedside, your description by phone needs to cut through the inevitable “bystander effect” fog and help them see why this individual patient needs them personally to act on their behalf.
  • Affirm those who do the right thing.  Take some time to thank a General Medicine or Pediatric attending who does do the right thing and takes ownership.  So, yeah they have mastoiditis and ENT won’t admit them – but we will take care of the patient, keep them on IV antibiotics, and circle back with ENT in the morning.  I admire physicians who will do the right thing for the patient, even if it costs them time and energy.
  • Humble yourself to help the patient.  Doing things like walking a disc to the radiology file room to upload outside images or organizing disparate records a family brought is not “scut work.”  If this is what we need to do the help the patient, it’s not “beneath us” to do it.  Actually, this is humility in action – working together for the good of the patient, even if that means doing a little extra.  In the modern era, this is “the mechanics of doctoring.”
  • Time pressure may tempt us to act in ways we shouldn’t.  The biggest reason we don’t act like a Good Samaritan and stop to help isn’t necessarily a character flaw as much as it is because we are in a hurry.
  • It’s a good kind of hurt.  This editorial hit me where it hurts and has made me reexamine the way I approach these scenarios.  I hope to take these lessons into my shift this afternoon.

The Not-My-Problem Problem.  N Engl J Med. 2019 Feb 28;380(9):881-885. doi: 10.1056/NEJMms1813431.

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