FOAMcastini – SMACC Day 3

(ITUNES OR Listen Here)

We are bringing you pearls from conferences we attend including SMACC (#smaccUS).  This conference was amazing and we enjoyed meeting everyone.  We look forward to seeing y’all at SMACC in Dublin June 13-16, 2016 and hope you check out the Free Open Access Medical education (FOAM) lectures from SMACC, in podcast form, until then.

Things in medicine aren’t always engineered to help us succeed. Engineering the environment smarter may make care safer. – Kevin Fong

  • Medication vials often look quite similar and in a busy, heated moment this may lead to medication errors.  Check out the EZdrugID project.
EZdrugID
Photo: Dr. Nicholas Chrimes

Analgesia, there’s more to it than medicine – Jeremy Faust

  • Distraction is a good thing.  Doing a painful procedure such as injecting local anesthetic? Distract the patient in tactile fashion by lightly scratching the patient proximal to the procedure. Alternative, music and videos can distract children and adults.
  • Calm music may reduce perception of pain.
  • Take advantage of child life, if you have them [AHRQ]!

The Glasgow Coma Scale is a problem – Mark Wilson (see this blog post)

  • The score doesn’t have intrinsic meaning. A GCS score can be associated with mortality ranging from 20-57%, depending on the individual components [Healey]
  • We’re really bad at assigning correct GCS scores to patients, even when we have cheat sheets [Feldman]
  • The interrater reliability of the GCS is abysmal [Bledsoe, Gill]
  • Describe the patient’s exam!

Shift work is disruptive – Haney Mallemat

  • Microsleep is dangerous, yet fairly common in the over tired provider
  • Replacing traditional night shifts with “casino shifts” may help.  These are often comprised of 2 short shifts from 10p-4a and 4a-10a with the notion that each provider would get sleep during the “anchor period” of the Circadian cycle, 2am-6am.  Small studies have shown this feasible, preferred by many, and perhaps perceived [Croskerry, Dukelow]

FOAMcastini – SMACC Day 1

(ITUNES OR Listen Here)

We are bringing you pearls from conferences we attend including SMACC (#smaccUS).  The overarching theme to Day 1 at SMACC?  Use your team- to keep you in check and for feedback.  Our cases and errors are opportunities for reflection. Dr. Cliff Reid reminded us to follow up our patients and outcomes and learn from it all, without letting our egos get in the way.   Dr. Simon Carley (St. Emlyn’s) gave a powerful talk on learning from mistakes later in the day; you will definitely want to listen to these when they come out.

The sub theme?  Experts don’t need algorithms and tests. But the novices? That’s another story.

Trauma – Weingart.  We won’t delve into his thoughts on ATLS here (hint: ATLS isn’t for experts).

  • Ignore the first automated blood pressure, it’s probably wrong.  Get a manual blood pressure.
  • Giving 3 units of blood in one hour? Prepare for massive transfusion, that means FFP, platelets, everything
  • If you go down the massive transfusion pathways, give an ampule of calcium every 4-6 units of plasma to combat the transfusion induced hypocalcemia from citrate.
  • The Shock Index (HR/SBP), isn’t as exciting as we once thought. It may be a guide, but not reliably so.

Pain – Strayer

  • Analgesia doesn’t = opiates.  Think about local analgesia.
  • Pain as the “5th vital sign” – probably more harmful than helpful [Gussow]
  • In fact, in 2009, there were

Polypharmacy – Juurlink

  • Trimethoprim/sulfamethoxazole and ace-inhibitors/angiotensin receptor blockers, used in combination can lead to hyperkalemia and, in some cases, death [Juurlink et al]
  • Acetaminophen, at just 2 grams/day, can elevate the INR in patients on warfarin [Pinson]. Acetaminophen is still probably the analgesic of choice, but something to be aware of

Sepsis 

  • Lactate is not a measure of tissue hypoxia/anaerobic metabolism [Marik et al]
  • Too much fluid is not a good thing = iatrogenic salt water drowning [Marik et al]
  • Patients may need vasopressors.  If they do, don’t delay based on central access.  Vasopressors are ok through good peripheral lines for a day or so. [Loubani et al, Mayo et al] However, we should probably place the lines when we’re safely able.
    • Of note, this does require strict protocols. Ex: Mayo study had stringent inclusion criteria
Mayo et al
Mayo et al