Much has been written regarding the benefits of apneic oxygenation. The physiological underpinnings are sound with minimal logistical and resource based costs. As such it has enjoyed widespread adoption throughout the Emergency Medicine and Critical Care world. Despite its popularity, the evidence supporting its use has been less inspirational. Recently, a meta-analysis published in Annals […]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
EM Nerd-The Case of the Bridge to Nowhere Continues
So often we apply qualitative dichotomies to quantitative differences even when questionable clinical distinction exists. Such is the case with the general interpretation of a recent article published in Resuscitation. Huis in ’t Veld et al examined video recordings of real life Emergency Department resuscitations of patients in cardiac arrest (1). Over a one year […]
EM Nerd-An Addendum to the Case of the Tarnished Standard
In a previous post we discussed the use of IVC variation and the concept of fluid responsiveness. Despite a strong physiological basis, no studies examining the use of fluid responsiveness to guide resuscitative efforts in patients with septic shock have been shown to improve patient important outcomes. Shortly after this post was released, Critical Care […]
EM Nerd-The Case of the Tarnished Standard
Anyone who has spent some time in a cardiac intensive care unit understands the physiologic appeal of the intra-aortic balloon pump (IABP). Anecdotally its use improves multiple clinical endpoints that for years have been considered surrogates for patient important outcomes. And yet, despite these physiologic advantages when examined in a rigorous fashion, IABPs have failed […]
EM Nerd-The Case of the Failed Assumptions
Whether you are aware of it our not, three major assumptions are present when employing any diagnostic strategy in the Emergency Department. First, that the diagnostic test in question will identify a group of patients at risk of a poor outcome due to an otherwise undiagnosed process. Second, there is an effective therapeutic intervention that […]
EM Nerd-A Case of Shadows Continues
The use of point of care ultrasound (POCUS) in the Emergency Department is a Bayesian playground for those willing to indulge. Take for example the performance of POCUS in the diagnosis of pulmonary embolism (PE). The poor sensitivity of bedside echocardiography to identify all-comers with pulmonary embolism is well documented. Most series cite a sensitivity […]
EM Nerd-The Case of the Tardy Delegate
We have discussed the dangers of surrogate outcomes at length, but none are more evident to an Emergency Physician than the time-based metrics we are subjected to on a daily basis. The latest of these temporal surrogates forced upon us is the 3-hour bundle of care in patients presenting to the Emergency Department with symptoms […]
CC Nerd-The Case of the Anatomic Inaccuracy
A recent publication in Chest by Semler et al examined the utility of the ramped position for the emergent intubation of patients in the ICU (1). The results not only call into question our use of this technique, but more importantly the outcomes we use to evaluate the efficacy of airway interventions outside the pristine […]
EM Nerd-An Addendum to The Case of the Incidental Bystander
The October 2016 NEJM publication of the PESIT trial by Prandoni et al set the world of social media ablaze (1). There were the standard fear mongering headlines noting that 1 in 6 patients admitted to the hospital following syncope had a pulmonary embolism. This was followed by a reactionary flurry of commentary by the […]
EM Nerd-The Case of the Bridge to Nowhere
The use of mechanical cardiopulmonary resuscitation (mCPR) has been a polarizing topic almost from its inception. The idea, a simple one. Why not build a machine that is capable of doing perfect chest compressions? A simple, effective way to eliminate the inconsistencies common to manual chest compressions. And yet, despite building a number of devices […]
EM Nerd-The Case of the Shadowy Spector
The shadow of the long-term sequelae of submassive pulmonary emboli has stalked the hearts and minds of Emergency Physicians. The use of thrombolytics to prevent these ramification has previously been supported primarily with surrogate data, physiological reasoning and communal anecdotal experience. Thrombolytics for submassive pulmonary emboli have failed to demonstrate an improvement in short-term mortality […]
EM Nerd-A Brief Addendum to the Adventure of the Red-Headed League
What is the clinical significance of a post traumatic seizure (PTS) in children presenting to the Emergency Department following minor head trauma? This is a question surrounded by myth and dogma. As with most questions regarding traumatic brain injury (TBI) in children, the PECARN authors have come to our aid. Badawy et al published a […]
EM Nerd-The Case of the Inconsequential Truth
There have been a number of publications recently maligning the use of morphine for the treatment of acute coronary syndrome (ACS). The hypothesis proposed is that morphine slows the absorption of the oral p2y12 inhibitors, such as ticagrelor, delaying the dual- platelet inhibition desired by cardiologists worldwide. The most recent data supporting this hypothesis was […]
EM Nerd-The Case of the Aimless Company
No one can deny the severity of the opioid crisis in which we currently reside. But what is less clear is whether we are innocent bystanders, facing the consequences of someone else’s problem, or directly responsible for causing a portion of the addiction we are currently witnessing. In a recent publication in the NEJM, Barnett […]
CC Nerd-The Case of the Elusive Mirage
Tales are often told of an exhausted travel who has lost their way in the desert, and are drawn astray by the the sight of a lush oasis. But as they draw close, their salvation vanishes only to reappear on the distant horizon. This optical tormentor continues to lead the hapless travelers further and further […]
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