In February of 2013, the American College of Emergency Physicians published a Clinical Policy statement regarding the use of tissue plasminogen activator (tPA, Alteplase®, Genentech) for the treatment of acute ischemic stroke.
Emergency physicians in our group ask that question daily with a combination of hope and fear. We’re not referring to one of our on-call psychiatric colleagues, rather to which one of us has the responsibility to spend roughly two hours or more during and after our shifts caring for the 10 to 20 behavioral health holding patients in one of our EDs. It’s not uncommon for the “Psych Doc” to average 10 interruptions per hour regarding Psych ED patients.
Emergency Physicians Monthly has teamed up with the board prep pros at Rosh Review to bring you a mini board review, so that you can test yourself on a regular basis and track your progress. The following is the test – and answers – from the February edition of Emergency Physicians Monthly. Questions about the test? Talk back on Twitter @epmonthly.
The following is an example of a typical cockpit to tower communication during landing. Pilot: “Cincinnati Tower, we’re six miles southeast and control VFR.” Tower: “Runway 18, wind 230 degrees, five knots, altimeter 30.” Pilot: “Roger, Runway 18.” Tower: “Have you in sight, cleared to land.” In safety critical industries such as commercial air travel, processes have been put into place to limit interruptions during certain tasks. The “sterile cockpit rule” limits non-essential communication and activities during taxi, takeoff, landing, and flying below 10,000 feet.
The newest release from the Oregon Health Insurance Experiment seems to portend doom for both emergency medicine and the Affordable Care Act.1 Even the New York Times’ headline is scary: “Emergency Visits Seen Increasing With Health Law.”2 Fortunately, things simply are not that bad.
Not too long ago, severe hypoxia in the ED was treated with a 15 lpm non-re-breather, bag mask ventilation, and preparing for intubation. CPAP systems have changed the rules and we often now use CPAP to avert intubation or to maximize pre-oxygenation prior to airway management. CPAP prior to intubation (with the use of pharmacologic assistance for sedation) was termed Delayed Sequence Intubation (DSI) several years ago by Dr. Scott Weingart.
The use of lytics in stroke is perhaps the most controversial therapy in emergency medicine; too many EPs have evaluated the data, starting with the NINDS trial in 1995, to recent trials like IST-3, and decided that tPA is not worth the risk.
If time is money, emergency medicine needs to take another look at electronic medical records which introduce inefficiencies into the medical system. A recent study brought this issue of ED efficiency – and its impact on revenue – into sharp focus. The study asks the question, “Just how long are physicians actually spending on the computer?”
Louis Binder: 1954-2014. The emergency medicine community recently lost a great physician, scientist and educator who made a lasting impact on our specialty. Louis S. Binder passed away on January 16, 3 months short of his 60th birthday.
In room 7 there is an 85-year-old puffing away on CPAP who was just discharged from the hospital two days ago and is back for worsening congestive heart failure (CHF). In room 8 there is an agitated advanced Alzheimer’s patient whose J-tube fell out at the nursing home. And in room 9 there is a cirrhotic, COPD hypotensive dialysis patient with pneumonia and a room air sat of 85%.