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SAEM Clinical Image Series: Pitching Pain

pitching pain

A twenty-year-old right-handed male presented to the emergency department with a past medical history of right coracoid impingement, and three months of increasing right shoulder pain that became suddenly worse. He had a right shoulder arthroscopy nine months ago and played a full season as his baseball team’s pitcher over the past four months. He endorsed no exacerbating symptoms other than movement and has only taken naproxen over the counter for this pain. He denied any family history of clotting disorders.

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By |2020-10-17T21:13:38-07:00Oct 19, 2020|Academic, Emergency Medicine, SAEM Clinical Images|
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SAEM Clinical Image Series: Knee Pain

knee

A fifty-six-year-old male with a past medical history of legal blindness and remote right quadricep tendon rupture presents to the emergency department via emergency medical services (EMS) after a mechanical fall, complaining of left knee pain. According to the patient, he is in his regular state of health and was walking with his cane when he had a mechanical fall on the sidewalk after tripping on an unknown object and falling onto his left knee.

The patient did not hit his head, did not lose consciousness, and has no head, neck, or back pain. The patient states that he fell directly onto his knee and felt a popping upon hitting the ground, and remembers all events surrounding the incident. The patient was not ambulatory prior to coming to the emergency department.

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By |2020-10-17T21:39:44-07:00Oct 19, 2020|Academic, Emergency Medicine, Orthopedic, SAEM Clinical Images, Ultrasound|
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Anticoagulant Reversal in Hemorrhagic Stroke

anticoagulant equal podcast

Acute management of cerebrovascular accidents can be challenging enough, but questions about anticoagulant reversal in the setting of hemorrhagic stroke add another layer of complexity. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Joshua Goldstein (Massachusetts General Hospital, Harvard Medical School). Dr. Goldstein addressed common anticoagulants and their reversal agents, summarizing available literature to inform clinical practice. We present highlights from this discussion with Dr. Jason Woods.

What is the goal of anticoagulant reversal?

Since it is impossible to go back in time to prevent intracranial hemorrhage (ICH), the focus of management for hemorrhagic stroke should be to prevent further bleeding and allow brain tissue an opportunity to recover. The goal of anticoagulant reversal in patients with ICH is to decrease ongoing bleeding.

Warfarin

Warfarin is a vitamin K antagonist. Since vitamin K is required for the processing of coagulation factors II, VII, IX, and X, patients on warfarin have decreased amounts of these factors in circulation. To increase the availability of these factors, countering the effect of warfarin therapy can be two-fold:

  1. Replenish vitamin K to allow the production of new factors.
  2. Provide replacement of these factors directly.

Vitamin K supplementation will not provide immediate effect, and it may take up to 24 hours for the production of new coagulation factors. While it should be given early, patients also require factor replacement acutely.

Fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) can be given to supplement coagulation factors.

  • FFP carries each of the 4 needed factors in addition to other clotting factors.
    • The cost of FFP is low.
    • Transfusion will take some time as it will require ~ 1 L volume.
  • PCC, marketed as Kaycentra in the US, consists of concentrated Factor II, VII, IX, X, and proteins C and S.
    • The cost of PCC is higher.
    • Transfusion is quick, ~70 mL, and leads to rapid correction of INR.

Studies have shown PCC to be associated with faster INR reversal, less ICH expansion, and a non-statistical trend toward decreased mortality [1]. PCC does carry a theoretical risk of thromboembolism given the rapid correction, but no evidence exists to suggest that this is the case.

Direct Oral Anticoagulants (DOACs)

There are 2 categories of DOACs:

  1. Factor II inhibitors (e.g., dabigatran)
  2. Factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban)

Approach to reversal: remove the inhibitor to allow normal function of already existent Factor II or Xa

  • Time
    • Time can be thought of as a reversal agent. Most DOACs have a half-life ~12 hours. If the timing of the last dose is known and it was hours ago, there may not be much medication left to reverse.
  • Monoclonal antibodies
    • Reversal of dabigatran can be achieved with the use of a monoclonal antibody, idarucizumab, to bind up circulating inhibitor.
    • Reversal of Factor Xa inhibitors can similarly be attempted with the use of monoclonal antibody andexanet. Andexanet is notably more expensive than idarucizumab.
  • PCC
    • PCC can be used off-label to outcompete circulating inhibitor with extra coagulation factors and increase the number of functional factors.

It should be noted that there are no reliable tests for measuring DOAC activity.

Dual Antiplatelet Therapy (DAPT)

The most common agents are aspirin and Plavix (clopidogrel). The issue with patients on these antiplatelet agents is not a lack of platelets, but the presence of medication that suppresses normal platelet function. Theoretically, if one could provide extra platelets, the inhibiting agent could be saturated and the remaining platelets provide some functional activity.

The PATCH trial demonstrated, however, that platelet transfusion led to significantly worse outcomes [2]. While there is no readily available reversal agent for DAPT, platelet transfusion should be avoided. In fact, observational data suggest that patients on single antiplatelet therapy don’t fare worse and may not need reversal like those with DAPT [3].

Conclusions

Warfarin reversal

  • IV vitamin K + PCC (or FFP)

Dabigatran reversal

  • Specific agent: Idarucizumab
  • Non-specific agent: PCC

Factor Xa inhibitor reversal

  • Specific agent: Andexanet
  • Non-specific agent: PCC

Antiplatelet reversal

  • No available agent
  • Transfusion of platelets associated with worse outcomes.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

References

  1. Steiner T, Poli S, Griebe M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol. 2016;15(6):566-573. [PMID: 27302126]
  2. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613. [PMID:27178479]
  3. Khan NI, Siddiqui FM, Goldstein JN, et al. Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes. Stroke. 2017;48(7):1810-1817. [PMID:28596454]
By |2024-04-19T21:52:51-07:00Oct 16, 2020|Academic, Emergency Medicine, Neurology|
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How I Work Smarter: Geoff Comp, DO

Geoff Comp

One word that best describes how you work?

Deliberate

Current mobile device

iPhone 7

Computer

MacBook Pro

What is something you are working on now?

I am working on a series of EM department recommendations for the treatment of various environmental conditions, including heat associated injury and hypothermia, with multiple residents interested in wilderness medicine.

How did you come up with this Idea/Project?

Like all great projects, these were developed while chatting about interests over beers! We reviewed current recommendations from various sources during a wilderness medicine interest group meeting and discovered the department does not have official guidelines for these topics.

What’s your office workspace setup like?

Unfortunately, most work is done on the couch. When I need a truly dedicated space, I use my wife’s home office for multiple monitors and a desk.

What’s your best time-saving tip in the office or home?

Rely on a schedule! Be mindful and deliberate with your time so you can focus on a specific project for a shorter period of time in a day and know the boundaries of a new task. My calendar has brief “work periods” of 1.5 hours, where I turn off external alerts/distractions and plug away at a predetermined list of goals for one project. Also, use applications that will communicate with all of your devices seamlessly. If your email, calendar, to-do list, personal finance, etc. don’t play well with all of your devices, you won’t use them.

What’s your best time-saving tip regarding email management?

Don’t use it as a to-do list. I work hard to go through emails in the morning and at night and clear out or address them. If it is a request for a task or a new project/opportunity, I will respond right away with acknowledgment and let the person know I will give a full response before a deadline. Then that task gets added to my own to-do list, rather than the constant reminder and irritation of a positive email balance that continues to spiral out of control.

What apps do you use to keep yourself organized?

Apple Calendar app. My work, personal, and family calendars all get pushed to this. I have sub-calendars for to-do lists, exercise, work meetings, etc. I always open this up and make sure I am available before agreeing to a commitment.

I also recently switched to Microsoft To-Do after the app “Wonderlist” was acquired by the company. It allows me to create a specific “next step” action items for big projects and allows for some success momentum as I see progress. I can make personal deadlines and reminders as well as assign tasks to a daily to-do list.

How do you stay up to date with resources? (FOAMed, CME, Current Events, etc.)

With targeted subscriptions and personal organization. I subscribe to only a handful of resources that are automatically emailed to me or populate my podcasting app. It is very easy to get overwhelmed by all of the incredible resources out there. I use Feedly as my aggregator and will scroll through frequently. After I exhaust my “go-to” resources, I search for Google FOAM.

What’s your best time-saving tip in the ED?

Identify roadblocks to your flow and address them early on to decrease your aggregate cognitive load over the duration of your shift. Procedures and in-depth exams take priority so I can free up that mental space and be ready for more patients. #StopPuttingOffTheLumbarPuncture

ED charting: Macros or no macros?

Absolutely. I use “dot-phrases” when documenting and have a pre-populated chart. If you use macros, make sure you either created them yourself or are very aware of everything included in it and ultimately in your note. You always want to make sure every portion is reviewed to ensure all of the abnormal findings are changed from your prepopulated “normal exam.”

Advice

  • What’s the best advice you’ve ever received about work, life, or being efficient? (Give multiple if you have them.)

Have and rely on a family and personal time calendar. I tend to have a self-inflicted busy schedule due to projects and work events, and it is easy for me to see free time and fill it up with work. However, I know it is essential for me to prioritize my family and ensure my wellness. My wife has access to edit my electronic calendar, and we frequently block off and reserve time for date night or time with friends. This helps me turn off “work brain,” as I am forced to complete my daily goals before spending time together, and I am not always thinking of my other projects or work.

Prioritize your work, not someone else’s. It is easy to start the day looking at your email and complete tasks like getting documents signed, responding to requests, and completing EMR training modules (yuck). These are all based on someone else’s timelines rather than your own. It is easy to go through a large chunk of time in your day completing tasks without making progress towards your personal goals and ultimately feel like you were “busy” but not “productive.” I set aside time blocks where I don’t respond to emails/slack/text messages and focus on one of my own projects.

Identify all of the small steps needed to accomplish a big goal and give yourself some wins by completing the tasks. It is sometimes very daunting to think of how to start or end a new project or job. I spend some time being mindful of all of the smaller steps that will need to be completed before finishing a final product. If you set and complete specific, measurable, and time-sensitive goals, you will gain that momentum to finish that fantastic project!

  • What advice would you give other doctors who want to get started, or who are just starting out?

Never stop learning. When you finish residency, continue to take the same advice we give to new residents: read as much as you can, learn something new each day from a patient. We are fortunate to have the best job in the world, and we must continue to grow and learn, allowing us to provide the best care possible throughout our careers.

  • Is there anything else you’d like to add that might be interesting to readers?

Work with a mentor! Find someone you think has a sound system for organization or efficiency and reach out to them to ask what they do.

Who would you love for us to track down to answer these same questions?

  • Mike Gottlieb
  • Drew Kalnow
  • Luz Silverio

Read other How I Work Smarter posts.

By |2020-10-08T16:10:34-07:00Oct 9, 2020|How I Work Smarter, Medical Education|
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How I Work Smarter: Meenal Sharkey, MD

How I Work Smarter Sharkey

One word that best describes how you work?

Thoroughly

Current mobile device

iPhone 11 — my whole life runs because of this phone!

Computer

MacBook Pro — thank goodness for the iCloud that syncs my calendars, notes, and texts

What is something you are working on now?

Just finished the Grounded in EM curriculum and am now creating a Grand Rounds for Evidence-Based Medicine for Sepsis.

One of my weaknesses is public speaking and also evidence-based medicine presentations. I like the concept of sepsis in general, so I picked this topic on purpose. It combined a topic I enjoy and an area of weakness, in the hopes that I’ll become a better clinician and educator because of it — I present it in September so we will see!

What’s your office workspace setup like?

HAHA. I live in a state of chaos with three kids and my husband, a newly-minted EMS fellow after finishing an EM residency. I typically work at the dining room table or on the kitchen counter, either once the kids are napping or asleep, or during quiet time. My husband has a study, which I often use as it has a door that closes (and locks!), but with the quarantine and 3 little kids not in school or daycare, there is always a lot of banging on the door for entry! Pre-COVID, I would often drop my kids off to daycare, so they have lunch and a nap on days I needed to get work done and go to a coffee shop around the corner, and then pick them up once nap time was done. I would get 2-3 hours of uninterrupted work time, and wouldn’t miss much of their day as they had lunch and then a nap. I honestly get more done when I’m working outside of the house, as I am not seeing other tasks that may need done or around distractions (laundry, dishes, dog walks, couch and TV time, etc).

What’s your best time-saving tip in the office or home?

I have several “notes” in the notepad function on my phone and laptop that I regularly update: To-Do lists, notes on resident progress, email drafts, grocery lists, kids needs, web-searches that I want to do. Since the program updates across my phone and laptop, I can jot down notes during the day when I’m on the move, dictate emails while I’m at my kid’s tutoring, etc. I can pick up the work right where I left off when I have more focused time on my laptop once my kids go to bed or I have some quiet time during the day.

What’s your best time-saving tip regarding email management?

I have three email addresses (one for personal, work, and clerkship/faculty). Within each, I have created filters for specific email addresses that auto-tags the emails. That way, I can quickly browse through and not be overwhelmed. I try to do my best to keep a zero-inbox, which for me is hard since I have a lot of FODSI (fear of deleting something important). Instead, I opt to have everything tagged so I can quickly archive when I feel like I have addressed the email.

What apps do you use to keep yourself organized?

I use the Notes function on my computer quite a bit! I have a shareable calendar with my husband and my parents to keep track of the logistical aspect of shifts, kids, after-school activities, etc. Basic, I know, but it works for me!

How do you stay up to date with resources?

I like to really make the most of my commute, so I’m a big fan of listening to Rebel EM and EMRAP on my drives into work. I get on Twitter a few times a week to see what is new there. I also really like JournalFeed and Pediatric EM Morsels for tidbits that go to my email, and will catch up on these every few days. I usually get my current events from my husband as this is an area that he likes to stay on top of, and I….don’t.

What’s your best time-saving tip in the ED?

  • While working, I make a list of the room number, the patient/CC, and then two boxes. One box signifies I’ve completed the HPI, PE in their ED chart, and the second box means I’ve completed the EKG/MDM. I cross out the entire line once I’ve signed the note. This keeps me on top of my notes, as that tends to be the area where I can quickly become behind. It also entices the type-A in me to check off the unchecked boxes!
  • The nurses are essential for patient throughput. I update my nurses on my plans for patients, and so they are moving the patient through their course actively, rather than reacting to orders in the computer. If you see a nurse starting an IV at the bedside, alert him or her that you need blood cultures, lactate, VBG, ammonia, etc, so that they don’t have to go back in afterward. Alert them of the meds/fluids you will be ordering if you’re all in the room together so that they can go to the med room rather than go to the computer to discover they have ordered. Do your best to batch your orders rather than trickling them in as this is extremely frustrating for them and slows your turn-around time! The nurses are an excellent resource for the vague/nebulous patient complaints, to get a different perspective for what the patient really wants or is concerned about.
  • I also have perfected my clean catch urine sample spiel, which I recite while walking patients to the bathroom!
  • I am especially more vigilant of specific tasks in the last 3 hours of the shift! Prioritize pelvic exams early in the patient course!

ED charting: Macros or no macros?

I do use macros, but I am deliberate about confirming that all the auto-populated areas are true! My biggest time savers are a pre-populated neuro exam, back exam, and extremity exam, as I do the same thing every time.

Advice

  • What’s the best advice you’ve ever received about work, life, or being efficient?

One of my senior residents told me once: “The goal is to get out on time, with your notes done, and make decisions your mom would be proud of” — I loved that! I love practicing medicine, but I also love leaving work behind to spend time with my family. Rather than finding a balance that suggests equal weight, I consider all my various roles as a massive juggling act, re-focusing on the task that is my hand, and then on to the next. And I wouldn’t have it any other way!

  • What advice would you give other doctors who want to get started, or who are just starting out?

In the beginning, it is typical to have self-doubt, but that WILL go away! You trained for this, and you ARE good at this. It takes a little while to get your bearings in a new role, so give yourself a little time and a lot of grace.

  • Is there anything else you’d like to add that might be interesting to readers?

As cliche as it is, find something outside of work that you LIKE. You don’t even have to be good at it, just enjoy doing it! It will replete you on days on which you feel like you don’t have anything left.

Who would you love for us to track down to answer these same questions?

  • Laryssa Patti
  • Brian Barbas
  • Eric Blazer

Read other How I Work Smarter posts.

By |2020-09-17T16:51:51-07:00Sep 18, 2020|How I Work Smarter, Medical Education|
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IDEA Series: 3D-printed pediatric lumbar puncture trainer

Pediatric lumbar puncture trainers are less available than adult trainers; most are the newborn size and quite expensive. Due to age-based practice patterns for fever diagnostic testing, most pediatric lumbar punctures are performed on young infants, and residents have fewer opportunities to perform lumbar punctures on older children.1 Adult lumbar puncture trainers have been created using a 3D-printed spine and ballistics gel, which allows for ultrasound guidance.2 No previous model has been described for pediatric lumbar puncture.

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By |2024-04-09T14:18:42-07:00Sep 16, 2020|IDEA series, Medical Education, Neurology, Pediatrics, Simulation|
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