Does physician altruism influence quality metrics? This study suggests yes.
45 physicians were defined as “altruistic” based on their willingness to share a $250 cash prize with a stranger in an on-line version of the dictator game, something you might have played in an economics class.
Of 250 physicians drawn from primary care and cardiology, 45 met the definition of altruistic and 205 did not.
Overall, patients of altruistic physicians:
The authors suggest that this difference may be on account of altruistic physicians being more willing to consider the appropriateness of tests or treatment or “devote more time and energy to their patients.”
They also note that while most physicians were categorized as not altruistic, at 18% this group of physicians exceeds the 5% of the general US population that would meet this definition.
Perhaps there is something quantitatively demonstrable to being a “good” doctor.
See https://jamanetwork.com/journals/jama-health-forum/fullarticle/2824419
Intravascular Volume and the IVC
Recent guidelines from anesthesia societies and recent literature emphasize the use of gastric POCUS for aspiration risk assessment. While the role of gastric POCUS in the emergency department is still being explored, one recent article highlighted its use in assessing patients with upper gastrointestinal bleeding (UGIB).
Performing Gastric POCUS:
Patient Position: Place the patient in the right lateral decubitus position, if unable can perform in supine position.
Probe Selection & Placement: Use a curvilinear probe in the sagittal position at the level of the subxiphoid process, similar to the longitudinal view of the proximal abdominal aorta.
Scanning Technique: Fan the probe left to right to assess the gastric antrum.
Interpretation of Gastric Antrum:
Empty Antrum: Appears as a "bull's eye" or flat, with no visible liquid inside.
Full Stomach: Distended antrum with floating contents.
Intermediate: Shows a small amount of anechoic fluid without floating contents.
Quantitative Evaluation:
It is also possible to perform a quantitative evaluation of the gastric antrum to further assess stomach contents, this may be more useful in patients with intermediate gastric antrum.
For more details, refer to the articles and videos cited.
This article serves as a reminder that trauma can and will precipitate adrenal insufficiency and crisis in those trauma patients who are on steroids pre-injury. Look for prednisone or hydrocortisone as well as autoimmune or rheumatologic diseases on pre-injury medication list and history. Consider the diagnosis in trauma patients with refractory hypotension not responsive to vasopressors. Replacement therapy with hydrocortisone is the therapy.
These authors looked at reported demographics, specifically focusing on sex and gender reporting, from studies in a number of high profile, multi-disciplinary fields.
They found that often only sex- referring biological sex assigned at birth- was reported. They found that the terms male/female as opposed to man/woman were the primary designations used, and a vast majority of studies and journals significantly underreported transgender, intersex and nonbinary demographics.
This study reinforces the need for more accurate reporting of SOGi data in research studies, to improve the equity of this patient population in up and coming research
CHECK-CALL-COMPRESS is the recommended algorithm by the International Liaison Committee on Resuscitation to teach school age children. Several studies show that school aged children are highly motivated to learn and perform CPR. They also serve as CPR multipliers meaning they go home, talk about what they have learned and inspire others to learn.
By age 4, children are able to assess the first step in the chain of survival - CHECK - assessing for responsiveness and breathing. By age 6, children can dial the emergency number and give the correct information for the location of the call. By age 10-12 children are able to get correct chest compression depths and ventilation volumes in CPR manikins. Hands-on training is more beneficial compared to verbal only instruction.
Areas where CPR is taught to school age children as a part of the school curriculum have higher rates of bystander CPR.
Bottom line: CPR should be introduced to elementary school children.
Rectal injuries are rare and are usually associated with penetrating trauma or significant pelvic fracture from blunt injury. Diagnosis starts with physical exam including inspection for signs of trauma as well as a digital rectal exam looking for blood, bony protuberance and abnormal sphincter tone. Normal digital rectal exam does not exclude injury.
Imagining is important in making the diagnosis.
“Findings on CT associated with rectal injury include a wound tract extending to the rectum, a full-thickness wall defect, perirectal fat stranding, extraluminal free air, intraperitoneal free fluid, and hemorrhage within the bowel wall….A CT with any suggestion of rectal injury should therefore be followed up with rigid proctoscopy to confirm the diagnosis and location of injury, as a combination of CT and endoscopy has a sensitivity of 97% in the diagnosis of rectal injury.”
EMS may call the hospital to obtain online medical direction when a patient does not wish to come to the hospital. One difficult task faced by the physician at the hospital is determining the decision making capacity of the patient. There is currently no nationally recognized standard protocol for physicians providing EMS oversight in this situation.
The four components involved in the determination of capacity are: understanding, appreciation, reasoning and expression of choice. This study used a modified Delphi approach with 19 physician experts to develop standardized steps to guide best practices for physicians who are called in real time about a patient refusing EMS transport. Consensus was defined as 80% agreement.
The example worksheet with the compilation of recommendations is attached.
Getting reliable venous and arterial access is crucial when resuscitating critically ill patients. These lines can be difficult due to patient and situation specific variables.
Micropuncture kits contain a 21-gauge echogenic needle, a stainless-steel hard shaft/soft-tip wire, and a 4 Fr or 5 Fr sheath and introducer. The micropuncture kit offers several advantages that can help overcome difficult situations:
To use a micropuncture kit, gain vessel access with the needle and wire, railroad the sheath and introducer into the vessel, remove the wire, then remove the introducer. Now you have a 4 Fr or 5 Fr sheath in the vessel. This is typically used to introduce a normal central line wire.
For arterial lines, you can place them directly over the wire without dilation. Keep in mind that the 4 Fr sheath (1.3 mm OD) and 5 Fr sheath (1.7 mm OD) are larger than a typical arterial line catheter (18g = 1.27 mm OD). If you dilate then you will cause hematoma.
Find out where your department stores micropuncture kits and get familiar with their components. While it adds an extra step to the procedure, it could make the difference between securing the line or not.
Rectal injuries are rare. The majority are secondary to penetrating injuries. Trauma care providers “should have a high clinical suspicion of rectal injury with any missile with a trajectory near the rectum; transpelvic gunshot wounds; stab injuries near the perineum, buttocks, groin, or proximal thighs; or open pelvic fractures. A digital rectal examination with a focus on sphincter tone, presence of blood, palpable defect, or bony protrusion should be carried out. Of note, a normal digital rectal examination does not exclude rectal injury.”
Ct scan with IV contrast (not PO or rectal) is used to identify rectal injuries but will be diagnostic in only 33% of injuries.
Rectal Injury Grading Scale
| Grade | Injury Type | Description of Injury |
|---|---|---|
| I | Hematoma laceration | Hematoma or hematoma without devascularization Partial-thickness laceration |
| II | Laceration | Laceration <50% of circumference |
| III | Laceration | Laceration ?50% of circumference |
| IV | Laceration | Full-thickness laceration with extension into perineum |
| V | Vascular | Devascularized segment |
Shoulder Abduction Test aka Bakody’s Sign
Used clinically in the evaluation of patients with suspected cervical radiculopathy
Unlike Spurling’s test, where we create discomfort, this test attempts to relieve it.
Specifically, evaluates for nerve root compression at C4-C6/7
To perform:
Arm Abduction can be active or passive
3. Instruct the patient to hold this position for 30 seconds.
4.Observe the patient for any relief of symptoms (A positive test)
Decrease in pain, numbness, weakness or tingling
5. Repeat on the unaffected side for comparison.
Sensitivity: 17–78% Specificity: 75–92%
Note: when asked about what alleviates their pain, patients will frequently describe and demonstrate the maneuver.
Consider adding this simple maneuver in your assessment of patients with suspected symptomatic cervical radiculopathy
Hypernatremia in Pediatric patients is less common than other electrolyte abnormalities occurring in <1% of hospitalized patients. The most common cause is water loss, either from poor absorption in the cases of vomiting, diarrhea, malabsorption or insensible losses, or via diabetes insipidus. Congenital disorders may cause decreased thirst receptors resulting in inadequate intake. Finally, excess sodium intake can occur via hypertonic fluids, ingestions or hyperaldosteronism or hypercortisolism.
Symptoms are often nonspecific- including fatigue, vomiting, hypertonia or hyperreflexia in lower states, but may result in lethargy, mental status changes or seizures as levels approach and exceed 160mmol/L
Treatment is similar to adults - free water deficit should be calculated:
Total body water (%) x weight (kg) x [(serum Na)/140 - 1]
Total Body Water (TBW) varies by age:
24-31 weeks- 90%
32-35 weeks - 80%
Term - 12 months - 70%
12 months and up - 60%
IV fluids should be started with a goal of decreasing the sodium level by 0.5 mmol/L/h with close monitoring of sodium levels.
Historically, there has been limited and inconclusive data regarding the utility of Rh (D) immunoglobulin (RhIg) in preventing alloimmunization for patients with early pregnancy loss or abortion at <12 weeks gestation. Although previous guidelines recommended routine administration of RhIg in Rh(-) patients after abortion of pregnancy loss at <12 weeks gestation, updated recommendations have been published as of September 2024.
The following are the updated recommendations from ACOG for patients who are less than 12 0/7 weeks gestation and undergoing abortion (managed with uterine aspiration or medication) or experiencing pregnancy loss (spontaneous or managed with aspiration or medication):
-ACOG recommends forgoing routine Rh testing and RhIg prophylaxis
-Rh testing and administration of RhIg can be considered on an individual basis with the help of shared-decision making regarding potential risks and benefits
These updated recommendations are based on recent studies that show a very low likelihood (although not entirely zero) of Rh alloimmunization associated with these populations. Many other Obstetric expert guidelines (such as those from the World Health Organization, Royal College of Obstetricians and Gynaecologists, and the Society of Family Planning) mirror these recommendations.
Summary: Consider shared decision-making regarding RhoGAM administration in patients who have an abortion or early pregnancy loss at <12 weeks gestation.
Background:
Epinephrine administration is a critical component of treating severe allergic reactions, and delayed administration is associated with increased morbidity and mortality. Epinephrine auto-injectors are the current standard of care and allow for rapid administration in all care settings, but compliance issues can limit their use. The most common reason patient’s site for failure to administer or delayed administration of auto-injectors is needle phobia (particularly with pediatric patients). This has led to interest in developing needle-free epinephrine delivery devices that are easy to administer.
New Drug Approval:
This August, the FDA approved an epinephrine nasal spray (brand name: Neffy) for use as emergency treatment for Type 1 allergic reactions, including life-threatening anaphylaxis. The approval was based on four studies, including 175 total patients, comparing epinephrine 2 mg nasal spray with an epinephrine 0.3 mg intramuscular injection in healthy adults and children. These studies showed similar blood concentrations of epinephrine between treatment arms through 60 minutes after administration. In addition, both treatment arms showed similar elevations in heart rate and systolic blood pressure.
Bottom Line:
Epinephrine nasal spray is a newly approved option for the treatment of severe allergic reactions and anaphylaxis. While this approval was based on studies in healthy adults and children who did not currently have anaphylaxis, this medication may be worth considering for patients who have issues or concerns about using an injectable device to administer epinephrine.
Background:
Septic shock is a severe and common critical illness that is managed in the emergency department. Our current foundation of treatment includes IV fluids, empiric antibiotic coverage, vasopressor therapy, source control and corticosteroids for refractory shock. The levels of nitric oxide (NO) and hydrogen sulfide (H2S) are elevated in sepsis and associated with worse outcomes. Hydroxocobalamin is an inhibitor of NO activity and production and a scavenger of H2S [1,2]. Most of the current data is limited to observational studies looking at hydroxocobalamin in cardiac surgery related vasodilatory shock with few case series and reports for use in septic shock. The available data has shown an improvement in hemodynamics and reduction in vasopressor requirements in various vasodilatory shock states [2]. Chromaturia and self-limited red skin discoloration are common side effects but current data has not shown significant adverse events [3,4]. Patel et al, performed a phase 2 single-center trial to evaluate use of high dose IV hydroxocobalamin in patients with septic shock.
Study:
Results
Take home
There is a low risk of serious adverse events from high dose hydroxocobalamin use [3,4]. For now, it may be reasonable to consider in cases of septic shock refractory to standard care but there isn’t enough data to support its regular use yet.
The authors reviewed the literature surrounding use of pigtail catheters for traumatic hemothorax and found:
“these data support using percutaneous thoracostomy as a safe and reliable treatment option for hemodynamically stable adult patients with traumatic hemothorax and are backed by major trauma society guidelines including the Eastern Society for the Surgery of Trauma and the Western Trauma Association.1,3 It has the added benefit of the insertion being less painful with the understanding that the percutaneous thoracostomy can always be upsized to a thoracostomy tube.”
Emergency Medicine Cases offers these excellent tips on pigtail catheters placement. Their video/website is worth a look.
PEARL # 1 – LOCATION/LANDMARK: Minimize skin to pleural distance.
PEARL # 2 – ADEQUATE LOCAL ANESTHESIA: This can obviate the need for sedation.
PEARL #3 – DILATING: Do it in a controlled manner.
PEARL #4 – USING THE OBTURATOR: Needless to say, it is there for a reason.
PEARL #5 – INTERPLEURAL BLOCK: Provide your patient with ongoing analgesia.
PEARL #6 – STOPCOCK AND ONE-WAY VALVE IN THE CORRECT POSITIONS
PEARL #7 – USE A GOOD SUTURE: Don’t let that chest tube come out.
This Canadian study looked at the safety of paramedics using the modified Canadian C-Spine Rule to determine which pre-hospital blunt trauma patients required immobilization. These were MVC and fall patients predominately. Bottom line: appropriately trained paramedics can use the modified Canadian C-Spine rule to clinically clear cervical spines in the field.
| Result of Application | Paramedics’ Interpretation | Investigators’ Interpretation |
|---|---|---|
| Injury | No Injury | Injury |
| --- | --- | --- |
| Immobilization required (N) | 10 | 1,342 |
| Immobilization not required (N) | 1 | 2,668 |
| Sensitivity, % (95% CI) | 90.9 (58.7–99.8) | 90.9 (58.7 to 99.8) |
| Specificity, % (95% CI) | 66.5 (65.1–68.0) | 68.2 (66.7 to 69.7) |
| Positive likelihood ratio, (95% CI) | 2.7 (2.2–3.4) | 2.9 (2.4 to 3.5) |
| Negative likelihood ratio (95% CI) | 0.1 (0.0–0.9) | 0.1 (0.0–0.9) |
Background:
Despite a lack of reliable evidence, sodium bicarbonate (SB) still appears in various protocols as a potential therapy for patients in cardiac arrest. Local EMS protocols also endorse the use of (SB) in specific scenarios such as: tricyclic overdose and hyperkalemia. EMS systems struggle to articulate best practices with respect to indications for SB administration.
Patients/methods:
Study authors conducted a scoping review of existing literature. The review included in hospital and out of hospital patients with cardiac arrest. Despite multiple studies looking at this question, a total of 12 were included in the final analysis. Criteria for inclusion were as follows: RCT or observational studies looking at patients aged 18 or older who experienced a cardiac arrest. Important outcome metrics incorporated: neurological recovery and survival to discharge.
Results:
The retrospective review failed to demonstrate a reliable association between survival and administration of sodium bicarbonate. Despite significant limitations (different study populations, retrospective designs), there remains insufficient evidence to consider routine administration of bicarb in the setting of cardiac arrest.
Bottom line:
Empiric administration of SB is not linked to a reliable benefit. SB may be considered for specific indications (tricyclic overdose, hyperkalemia) but is unlikely to improve outcomes such as neurologic recovery or hospital discharge. EMS systems should avoid recommending routine SB administration for patients with out of hospital cardiac arrest.
Title: Albumin Versus Balanced Crystalloid for the Early Resuscitation of Sepsis: An Open Parallel-Group Randomized Feasibility Trial— The ABC-Sepsis Trial
Settings: 15 ED in the United Kingdom. This study is a feasibility study but it looked at mortality as a primary outcome.
Participants:
• Patients with Sepsis, with their National Early Warning Score (NEWS) ? 5 (These patients have estimated mortality of 20%). IV fluid resuscitation needs to be within 1 hour of assessment.
• 300 Patients were randomized to receive balanced crystalloids or 5% human albumin solution (HAS) only, within 6 hours of randomization.
Outcome measurement: 30-day mortality, Hospital length of stay (HLOS)
Study Results:
• The median time for receiving IV fluid from randomization was 41 minutes (HAS) vs. 36 minutes (crystalloids).
• Total volume of IV fluid per Kg in first 6 hours 14.5 ml/kg (HAS) vs. 18.8 ml/kg (crystalloids).
• Other interventions (vasopressor, Renal replacement therapy, invasive ventilation) were similar.
• Complications (AKI, pulmonary edema, allergy) were lower for Crystalloids group
• Median hospital LOS = 6 days for both groups.
• 90-day mortality: 31 (21.1%) (HAS) vs. 22 (14.8%) (Crystalloids), OR 1.54 (95% 0.8-2.8)
Discussion:
• Total volumes for resuscitation in the first 6 hours was 750 ml (HAS) and 1250 ml (crystalloids). This signified a trend toward lower total volume of resuscitation (remember that 30 ml/kg recommendation)
• The 2024 guidelines from Chest (REF 2) suggested that: “In Critically ill adult patients (excluding patients with thermal injuries and ARDS), intravenous albumin is not suggested for first line volume replacement or to increase serum albumin levels. Therefore, we should not give patients (except for cirrhosis or spontaneous bacterial peritonitis) albumin just to reduce the volume of fluid.
• The authors suggested that even a definitive trial in the future will not be able to demonstrate a significant benefit of using 5% albumin.
Conclusion:
There is lower mortality (numerical but not statistically) among the group with balanced crystalloids.
