The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

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Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

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You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

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A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

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This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
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5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

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Talking Points

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Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

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All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

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Nurses or other ancillary staff routinely perform the task of acquiring IV access, but at times they are unable to obtain access, which is important for laboratory evaluation or fluid or medicine administration. When this occurs, such as in an obese patient or a patient with IV drug abuse history, the onus falls on the physician to achieve intravenous access.

While several studies have shown increased success rates using ultrasound guidance during the establishment of central venous access, Costantino et al. sought to determine if ultrasound guidance for peripheral IV access in difficult to access patients would have similar results.

The study was designed to prospectively randomize patients who had a history of difficult access—due to obesity, history of intravenous drug use, or chronic medical problems—and had failed at least three attempts at access by a nurse. All patients who had a need for central venous access were excluded, as were pregnant patients, children, and those unable to consent. The patients were allocated to the ultrasonography-guided or the landmark and palpation (control) group based on the presentation to the ED on an odd or even day, respectively. The primary endpoints measured were IV access success rate, time from first percutaneous perforation to successful cannulation, time from request for physician-performed IV access to successful establishment of intravenous access (in order to also take into account time to find and set up the ultrasound machine), number of percutaneous perorations required, patient satisfaction, and complications from intravenous access.

A total of 60 patients were enrolled—39 into the US-guided IV access group, and 21 into the landmark and palpation group. The success rate for the ultrasonographic group was 97%, versus 33% for the control group. Patients undergoing US-guided required less overall time to establish IV access (13 minutes versus 30 minutes). The US-guided group also had less time to successful access from the first percutaneous puncture (4 minutes versus 15 minutes), had fewer percutaneous punctures (1.7 versus 3.7), and had a greater patient satisfaction (8.7 versus 5.7). There were no significant complications reported in either group.

While this study showed ultrasonography is an invaluable tool in aiding the physician in establishing IV access, it is notable that this study did employ a two-operator approach. Castantino et al. addressed this, mentioning a previous study showing no difference in success with US-guided peripheral IV access using either one or two operators. However, although it may not affect overall success of the peripheral IV placement, a single operator approach may or may not prolong the time to achieve access. Another limitation listed in the study was that, although there were three additional “odd” days, a larger than expected group was enrolled into the US-guided IV access group. The authors best explain this as a probable selection bias. In addition, the authors also thought it important to mention that those in the traditional group were allowed to attempt cannulation of the external jugular vein—as that is often what takes place in the “real world”. While this may introduce more bias, it would favor the control group and not the ultrasound group.
 

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