PV Card: Palliative Care Screening in the Emergency Department

What is Palliative Care? It is specialized medical care focusing on improving the care and quality of life for patients with advanced illness by decreasing suffering. It can be delivered concurrently with curative care. Early identification of patients who are likely to benefit is key. How do you decide whether your patient could benefit from a palliative care consult?

Hot off the presses

We just published in Academic Emergency Medicine a validated screening tool to identify ED patients who would benefit from palliative care [PubMed abstract].¹ In an effort to accelerate knowledge dissemination, the checklist is reproduced here in PV card form. Be sure to check out the thoughtful expert peer review below by Dr. Kate Aberger, who is the chair of the ACEP Palliative Care Section.

PV Card: Palliative Care Screening Tool

Adapted from ^1–3

George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J. Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs. Acad Emerg Med. 2015;22(7):823-837. [PubMed]
Grudzen C, Richardson L, Morrison M, Cho E, Morrison R. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17(11):1253-1257. [PubMed]
Wu F, Newman J, Lasher A, Brody A. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med. 2013;16(11):1362-1367. [PubMed]

By Naomi George, MD MPH|2022-01-10T16:49:39-08:00Aug 3, 2015|ALiEM Cards, Expert Peer Reviewed (Clinical), Geriatrics|

Trick of the Trade: Lactated Ringers for Sepsis Complicated by Hyponatremia

An 82-year-old female is brought into the Emergency Department by family for a several day history of progressive altered mental status. You initiate a broad workup. However, soon after initial evaluation, you are called back into the room. The patient’s vitals are as follows and concerning for septic shock and an alarming serum sodium level.

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By Kai Li, MD|2017-03-05T14:18:48-08:00Jul 16, 2015|Endocrine-Metabolic, Expert Peer Reviewed (Clinical), Tricks of the Trade|

Ultrasound For the Win! Case: 38-year-old pregnant woman with acute right-sided abdominal pain #US4TW

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this peer-reviewed case series, we focus on real clinical cases where bedside ultrasound changed management or aided in diagnoses. In this case, a 38-year-old pregnant woman presents with acute right-sided abdominal pain radiating to her flank.
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By Jeffrey Shih, MD, RDMS|2017-07-19T00:07:14-07:00Jul 14, 2015|Expert Peer Reviewed (Clinical), Ultrasound, Ultrasound for the Win|

Trick of the Trade: DIY Circulating Water Bath for Frostbite Treatment

A 26-year-old woman presented to an urban Detroit emergency department complaining of bilateral foot pain after walking outside in the snow for 30 minutes without shoes or socks. She was unable to ambulate secondary to the pain and swelling. Physical examination revealed bilateral pallor, doughy texture, and coolness to the touch. There was generalized tenderness to palpation throughout the digits. The overlying skin was edematous, although without signs of breakdown.

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By Ciara Barclay-Buchanan, MD|2018-01-30T02:28:16-08:00Jul 8, 2015|Environmental, Expert Peer Reviewed (Clinical), Tricks of the Trade|

EREM: Pitfalls and Perils of Emergency Department Discharge Instructions

In the emergency department (ED), failure to comply with discharge instructions has been associated with an increased rate of adverse outcomes for patients. ^1,2 There is tremendous variability in the information that is provided to patients in discharge paperwork. In some EDs, a simple handwritten discharge note is given to the patient, while in others, extensive, diagnosis specific pre-created instructions are provided to patients at time of discharge. To improve patient outcomes and reduce their medicolegal risk, providers must recognize pitfalls associated with discharge instructions and include two key elements as a part of all discharge paperwork.

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By Matthew DeLaney, MD|2016-11-11T19:37:15-08:00Jul 6, 2015|Expert Peer Reviewed (Clinical), Medicolegal|

Blast From the Past: Occult Sepsis, Lactic Acid, and Mortality

Severe sepsis and septic shock affect millions of patients worldwide and have high rates of morbidity and mortality as well as high resource utilization. The way we manage sepsis has changed quite a bit since the Rivers et al randomized controlled trial of early goal-directed therapy (EGDT) ¹ , which had an absolute decrease in mortality from 46% with “usual care” to 31% with EGDT. What we now know is that a proactive approach to septic patients will result in lower mortality rates and better outcomes (i.e. early identification, early intravenous fluids, and early antibiotics). Patients with sepsis are still missed despite the fact that we understand the benefits to morbidity and mortality with early recognition. In this blast from the past study from 2007, Howell et al ² answered the important question of does elevated lactic acid simply reflect a patient’s hemodynamic status or can it independently predict 28 day in-hospital mortality after controlling for other potential confounders in patients with sepsis. (more…)

By Salim Rezaie, MD|2016-11-11T19:37:14-08:00Jun 29, 2015|Critical Care/ Resus, Expert Peer Reviewed (Clinical), Infectious Disease|

Salicylate Toxicity PV card v2: Lessons in post-publication review

I was recently the author of a PV card for management of Salicylate Toxicity, which had some discrepancy with expert opinion. The point of contention was in regards to measurement of urine pH vs serum pH for alkalinization. In preparing the first version of the card, I began with notes from a recent toxicology rotation, and expanded by examining textbooks and review articles. Although there was mention of serum pH measurement, numerous sources emphasized urine alkalinization as the primary endpoint for the treatment of aspirin toxicity. Therefore I choose to include this on the size-limited PV card.

Despite review by numerous peers and colleagues, not long after publication we were met with concern from prominent toxicologists regarding an oversight in mentioning serum alkalinization. Utilizing the strengths of our blog and social media we were immediately able to initiate a discussion with experts on the topic.

Expert Peer Review Comments

Dr. Lewis Nelson of NYU was able to clarify that by prioritizing serum alkalinization, we will avoid the cerebral toxicity that is the primary etiology of mortality. Serum alkalinization should also facilitate urine alkalinization as well as allow time to arrange for hemodialysis. Dr. Bram Dolcourt from Detroit expanded that serum alkalinization and normokalemia alone do not guarantee an optimal urine pH and suggest measurement of both urine and serum. From Twitter, Dr. David Juurlink from Toronto also recommended measurement of both, stating his forthcoming publication will expand on the topic. Our own ALiEM clinical pharmacist Dr. Bryan Hayes also assisted with expert insight as I was revising the PV card.

My Reflections

As the ALiEM-CORD virtual fellow, I have had the challenging task of collaborating with experts in my field, while still very much in a learner role myself. I was fortunate enough to have been featured on a site that has a robust commenting system and pride in peer review, even if it is post-publication. There is certainly content on the web that may be inaccurate or ‘less-accurate’, and consumers of both FOAM and conventional publications, as always, should remain critical and review multiple sources. There is a broad range in teaching and practice based on region, and when we work together we can identify what is truly best practice. Hopefully this conversation and the forthcoming publication on the topic will translate into changes in practice and in the textbooks in the coming years. Luckily, utilizing the strengths of our medium, we are able to publish these corrections today.

PV Card: Acute Salicylate Toxicity

For those curious, here was the original version 1.

By Sam Shaikh, DO|2021-10-05T12:51:20-07:00Jun 15, 2015|ALiEM Cards, Expert Peer Reviewed (Clinical), Medical Education, Social Media & Tech, Tox & Medications|

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