Today, you are the sole EP on duty in a semi-rural, critical access hospital ED. As a matter of fact, you are always the only EP on shift. You were trained in a solid tertiary care EM residency with a level I trauma center, stroke center, and 24/7 cardiac cath lab facilities. You know all the clinical guidelines (all of which have been developed in tertiary care centers by academic faculty physicians) and all the tertiary care tricks of our trade.
A 65-year-old gentleman with hypertension and hyperlipidemia presents to your emergency department one evening complaining of continuous vertigo that began suddenly two hours prior to arrival. He notes significant head motion intolerance, is nauseated, and has vomited several times. On exam, he has horizontal nystagmus in lateral gaze, is very unsteady on his feet, but otherwise has a normal neurologic exam.
It’s a typical busy Saturday night in your ED. The next chart you pick up is a 15-year-old male with cough shortness of breath and chest pain for one day. He is tall, with normal vitals and in no distress, and you note decreased breath sounds on his right side. Chest X-ray confirms it: pneumothorax.
The results are in. According to the Fast-Mag study, IV magnesium given for stroke patients in the field doesn’t do anything therapeutically. That’s what was reported at the recently completed meeting of the American Stroke Association.
An elderly woman arrives from a nursing home with acute respiratory distress and altered mental status. She is febrile, hypoxic and hypotensive. She has moderate retractions, increased secretions and significantly diminished lung sounds. She has a signed current DNR/DNI.
Each year, approximately 300,000 people suffer out-of-hospital cardiac arrest (OHCA) in the United States.1 About one-third of these will have return of spontaneous circulation (ROSC), either en route to the hospital or in the emergency department (ED). Unfortunately, more than two-thirds of those with ROSC will not leave the hospital alive.
Droperidol has been used successfully in the emergency department (ED) and operating room (OR) for over 40 years. It has been employed with success for the treatment of headache, nausea, agitation, pain in opiate-tolerance and even the dreaded multidrug-resistant abdominal pain (MDRAP).1,2 Unfortunately, in 2001 the FDA issued a black box warning indicating there was a significant risk of cardiac arrhythmias with droperidol.
In an attempt to mitigate the high costs of medical malpractice insurance, decrease the number of multimillion dollar jury verdicts, and encourage physicians to provide medical care, some states have enacted laws to limit the liability of medical providers in medical malpractice cases. Capping noneconomic damages in medical malpractice cases is but one of the better-known methods that many states have utilized, but there are many others.
In November the American Heart Association released its shiny new guidelines for the management of cholesterol, and in the process set off a firestorm. Talk shows talked, pundits opined, and cardiologists postured. But in the center of it all there is an evidence base that offers a clear-eyed view. Do statins for healthy people save lives?
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.