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VEP Selected to Modern Healthcare’s Best Places to Work
Sutter Solano Medical Center ED Rated as “Kid-Qualified” by VEP
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Holly Mesikmen Named the Provider of the Year for 2012!
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UCLA Medical Center helps kids be less afraid of the ER, doctor
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Formerly with VEP at Sutter Solano Medical Center, Dr. Carson is featured in Contra Costa Times’“Hometown Hero” article!
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Valley Emergency Physicians welcomes three new members to our Board of Directors
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HEALTHeCAREERS Featured Employer Profile: Valley Emergency Physicians Medical Group
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Voting is currently in process for this year’s California ACEP Board of Directors!
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Valley Emergency Physicians’ Phil DaVisio, PA-C, published in the June 2014 ACEP Democratic Group Practice Section Newsletter!
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VEPeds White Paper
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Long Bone Fracture Pain Meds
Dear VEP Providers,
Below is a link to a one-page handout on OP-21, the national core measure for PAIN MEDS FOR LONG BONE FRACTURE. Study it for 2 minutes to learn all you need to know about OP-21. Be aware that starting in January, carpal bones will be included.
Most of our EDs have median times that are better than the national average of 54 minutes. Some of our EDs are in the top 10% nationally with median times under 34 minutes! Our goal for 2016 is to have every VEP ED in the top 10%.
Bottom line: Treat any painful condition as soon as possible, not just long bone fractures.
Thanks,
Robert Wyman, MD | Vice President of Quality
Tel: 925-482-2802 | Fax: 925-482-2838
rwyman@vephealthcare.com
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Clinical Decision Rules And Smartphone Medical Aps
Dear VEP Providers,
This link will take you to an excellent video that was recorded at the recent VEP Directors and Shareholders Meeting: https://kevinjones20.wistia.com/projects/gbe68q3640
The video is about Clinical Decision Rules (CDRs) and the best smartphone medical apps. The presentation was given by two of our VEP colleagues:
- Dr. Justin Chatten-Brown, ED medical director at Woodland Hospital in Woodland, CA, and VEP board member.
- Dr. Kevin Jones, ED assistant medical director at Sutter Solano Medical Center in Vallejo, CA, and Cal/ACEP board member.
CDRs can reduce testing, decrease turnaround times and LWBS, and increase patient satisfaction. Smartphone medical apps provide quick and easy access to useful tools and a wealth of information. Enhance your ability to provide high-quality, efficient, evidence-based care by viewing the presentation and incorporating the material in your practice.
Thanks.
Robert Wyman, MD | Vice President of Quality
Tel: 925-482-2802 | Fax: 925-482-2838
rwyman@vephealthcare.com
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Ebola Scare In A VEP ED
Dear Providers,
Fortunately, despite all of the Ebola preparations at VEP emergency departments over the past few months, only a couple of patients have had histories and symptoms suspicious for Ebola (so far). Below is the experience of Justin Chatten-Brown, MD, our ED medical director at Woodland Memorial Hospital in Woodland, CA, who initially thought he was being summoned to the ED for an Ebola drill this week. One lesson they learned at Woodland was that greater care is needed for PPE use. The following link is for a one-week old CDC video on PPE, so hopefully it is still current!
http://www.medscape.com/viewarticle/833907?src=ppc_google_acq_bola_vid
Rob Wyman, MD
Vice President of Quality
925-482-2802
rwyman@vephealthcare.com
I thought 6 AM was a little early for an Ebola drill, but dragged myself out of bed at 5. I walked into the emergency department thinking I would find us getting ready for a mock patient, but was instead met with a sense of urgency and seriousness I had not expected. I looked on the board and the patient in our isolation room had been in the department for an hour and a half. The administration and my colleagues told me it wasn’t a drill after all. I laughed it off, thinking they were pulling my leg. They told me to look through the window into the room, and it was only upon seeing the patient sitting in the bed, pale, diaphoretic, tachycardia in the 130s, that I realized this would have been a bit too hard to fake. The nurse sitting next to him at the computer in full PPE’s also appeared to be taking the situation very seriously.
It wasn’t much later that we were able to clear the patient for Ebola after obtaining more history, and in consultation with our public health department. It turns out our patient had very limited contact with a colleague who recently returned from Africa, but the symptoms were alarming. The patient had been in the emergency department for nearly 2 hours when we finally were able to run his laboratories and discover just how critically ill he was.
I imagine our extensive debriefing was much better than it would have been had this been a true “mock” patient. We were fortunate enough that this occurred early in the morning with a relatively empty department. We were also fortunate that the patient didn’t have Ebola, since at least two of our staff would likely have been exposed based upon improper donning and doffing of PPEs. Amongst numerous lessons learned from this experience, the standout is that while the Ebola scare may blow over soon, we are never as prepared as we would like to think. We all need to practice our preparedness, contingency plans, and how we will protect each other and our patients for whatever the next epidemic may be. As with our regular pediatric mock codes, we practice handling low incidence events knowing that if we don’t, lives will be lost. We should all consider our own biases and readjust our attitudes towards the current initiatives for Ebola preparedness.
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ACEP Choosing Wisely Recommendations
Dear VEP Providers,
Below is a link to the updated ACEP “Choosing Wisely” list of 10 recommendations. The recommendations are based on input from an expert panel of emergency physicians and the ACEP Board of Directors. The goal is to present evidence-based recommendations to providers about tests and procedures that may not be cost effective in some situations. When appropriate, you should consider discussing these recommendations with your patients in order to both educate them and gain their agreement regarding avoidance of such tests and procedures.
ACEP Choosing Wisely Recommendations
“Choosing Wisely” is a multi-year effort of the American Board of Internal Medicine Foundation to avoid care when harm may outweigh benefits. More than 80 medical specialty societies and consumer groups are participating along with ACEP.
Feel free to contact me if you have any questions, comments, or suggestions.
Thanks.
Rob Wyman, MD
Vice President of Quality
rwyman@vephealthcare.com
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VEP: 2 Minutes On Asymptomatic Elevated Blood Pressure In The ED
ASYMPTOMATIC ELEVATED BLOOD PRESSURE IN THE ED
As emergency department providers, we see elevated blood pressures on a daily basis. In some cases, this is reflective of an emergency medical condition which must be identified and stabilized. But what if the patient with elevated blood pressure is:
- asymptomatic, and
- denies any related symptoms, and
- has a normal physical exam?
The American College of Emergency Physicians (ACEP) periodically publishes clinical policies that answer specific clinical questions. ACEP recently released a policy addressing Asymptomatic Elevated Blood Pressure in the ED. Although these policies are not meant to establish a standard of care, you should feel very comfortable practicing in accordance with these recommendations. I encourage you to read the clinical policy yourself which outlines the evidence for the recommendations. See the link to the policy at the bottom of this email.
The short version of this policy is:
You do not need to do any screening tests, nor provide any medical treatment, for patients with asymptomatic elevated blood pressure.
The policy addresses whether performing screening tests to detect target organ injury, which would indicate a hypertensive emergency, is useful or necessary. This recommendation assumes that your history and physical exam are essentially normal (with respect to the hypertension).
Your chart documentation should include:
- History: absence of chest pain, shortness of breath, severe headache, or neurologic symptoms.
- Physical exam: normal cardiovascular, pulmonary, and neurologic exams.
For the purposes of the policy, the screening tests that you do not need to do are:
- ECG.
- CXR.
- Blood or urine tests to detect clinically occult abnormalities (e.g., anemia, cardiac ischemia, CHF, renal insufficiency).
In a nutshell, the ACEP recommendation for the asymptomatic patient with elevated blood pressure is:
Routine screening is not required. However, in select populations (poor follow up is their example), screening for an elevated creatinine may identify kidney injury that could affect disposition.
Similarly, the ACEP recommendation for the asymptomatic patient with markedly elevated blood pressure (considered by ACEP to be >180/110) is:
ED medical intervention is not required. However, in select populations (again, poor follow up is the example given) emergency physicians may treat in the ED and/or initiate outpatient therapy.
All of these patients should be referred for follow up.
These are Level C recommendations from ACEP. This means there are limited data but there is some level of consensus among experts regarding the recommendation. Of course, you should use your best medical judgment in any clinical scenario.
I think this policy really gives us the freedom to practice the way we see fit. There is a lack of evidence to support ordering any screening tests or acutely controlling asymptomatic elevated blood pressure. This may be a deviation from your usual practice, or what other healthcare workers and patients may be accustomed to. This information is for you to incorporate into your practice along with what you’ve learned in training and from your experience, colleagues, and continuing education.
Click for ACEP’s Asymptomatic Elevated Blood Pressure
I welcome your feedback on this topic. What do you do? What do you think is best practice?
Marc Futernick, MD
ED Medical Director at California Hospital Medical Center, Los Angeles, CA
Member of VEP Board of Directors
marcfuternick@aol.com
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Bronchiolitis Update In 3 Minutes
Dear VEP Providers,
Some providers may not be aware of the more recent evidence-based guidelines for bronchiolitis showing that most patients do not require blood tests, chest x-rays, or ED medications. These and other key facts are in a PDF “slideshow” (see link below) that was prepared by Jeff Lackore, PA-C (APC Regional Director) and edited by Ron Dieckmann, MD, MPH (Director of Pediatrics). The guidelines can reduce all of the following: ED length of stay, radiation exposure, number of painful needlesticks, and cost of care.
Bronchiolitis: Beware of ED Over-Management!
Please take 3 minutes to review the PDF. Feel free to contact me if you have any questions or concerns.
Thanks.
Robert Wyman, MD | Vice President of Quality
Tel: 925-482-2802 | Fax: 925-482-2838
rwyman@vephealthcare.com
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The Case For Advanced Practice Provider Ownership In Democratic Groups
VEP Physicians’ Phil DaVisio, PA-C,
Published in ACEP Newsletter!
Congratulations and thank you to VEP Physicians’ Phil DaVisio, PA-C, for his recent article published in the June 2014 ACEP Democratic Group Practice Section Newsletter! Phil wrote about “The Case for Advanced Practice Provider (APP) Ownership in Democratic Groups” which can be viewed in the original newsletter HERE.
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CDC Influenza Alert
Dear VEP Providers,
The flu has arrived. The CDC reports an increasing incidence of severe influenza across the country. The link below will take you to an important CDC alert about this. Below are excerpts from the alert and additional information about influenza. Please contact me if you have any questions or concerns. Thanks.
CDC Influenza Alert
Rob Wyman, MD
Vice President of Quality
VEP Healthcare, Inc.
rwyman@vephealthcare.com
- Clinicians should rapidly treat suspected influenza in:
• high-risk outpatients (see list in final item below);
• patients with severe, complicated, or progressive symptoms;
• all hospitalized patients. - The CDC recommends treatment with either oral Tamiflu (oseltamivir), inhaled Relenza (zanamivir), or IV peramivir. Note that inhaled Relenza probably should not be used in patients prone to bronchospasm. Be sure to check dosages and precautions before prescribing or ordering any of these drugs.
- RIDTs (rapid influenza diagnostic tests) have a high potential for false negatives. Therefore, decisions about starting antiviral treatment should not wait for laboratory confirmation.
- A history of influenza vaccination does not rule out influenza in an ill patient with clinical signs and symptoms compatible with influenza. Therefore, vaccination status should not impede the initiation of prompt antiviral treatment.
- For previously healthy, symptomatic outpatients who are not at high risk, antiviral treatment can be considered, especially if treatment can be initiated within 48 hours of illness onset. However, in these patients, antiviral treatment may afford only modest reductions in symptoms and length of illness.
- Patients with influenza should be advised not to work or go to school until afebrile to avoid infecting others.
- Early antiviral treatment is more effective at reducing morbidity and mortality. However, delayed treatment may offer benefit when started up to 5 days after symptom onset, which is something to consider except in previously healthy, low-risk patients.
- Patients admitted to the hospital with suspected influenza should be placed in respiratory (droplet) isolation.
- High-risk outpatients for whom treatment should be considered include:
• age < 2 or >64;
• chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), or metabolic disorders (including diabetes mellitus);
• neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, seizure disorders, stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
• immunosuppression, including that caused by medications or by HIV infection;
• pregnancy through 2 weeks after delivery;
• age <19 on long-term aspirin therapy;
• American Indians and Alaska Natives;
• morbid obesity;
• patients in nursing homes or chronic-care facilities.Again, please contact me if you have any questions or concerns. Thanks.
Rob Wyman, MD
Vice President of Quality
VEP Healthcare, Inc.
rwyman@vephealthcare.com
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VEP: 3 Minutes On Seizures – Part 2 of 2
SEIZURES IN ADULTS – STATUS EPILEPTICUS
A few weeks ago I wrote to you about the workup, treatment, and disposition of ED patients with unprovoked seizures, as well as the route of medication administration for ED patients with known seizures. A link to that article is below.
ACEP recently addressed which agents should be used to terminate ongoing seizure activity in adults. The policy affirms that the first line treatment is optimal doses of benzodiazepines, and assumes this has been initiated but has failed to abort the seizure activity.
The Level A recommendation is pretty obvious, and I expect that we are all doing this already.
- EPs should administer additional antiepileptic medication to patients with status epilepticus who have failed treatment with benzodiazepines.
- EPs may administer IV phenytoin, fosphenytoin, or valproate for refractory status epilepticus.
- EPs may administer IV levetiracetam (Keppra), propofol, or barbiturates for refractory status epilepticus.
- Hypoglycemia
- Hyponatremia
- Hypoxia
- Drug toxicity
- CNS infection
Regarding your first line options following optimal dosing of benzodiazepines, IV valproate appears to be as effective as phenytoin, and has fewer adverse effects.
In terms of second line agents, levetiracetam has a low incidence of hypotension and respiratory depression, which are both drawbacks of propofol. However, for intubated patients, propofol appears to be a very effective option.
Optimal Loading Of Antiepileptic Medication:
Finally, the ACEP policy on managing seizures in adults provides some guidance for optimal loading of antiepileptic medication, both for routine management and for status epilepticus. You can refer to the actual policy for more detail (see link below), but here are some key points.
- Carbamazepine: 8 mg/kg oral suspension is recommended as a single oral load, noting that oral tablets have slow and erratic absorption.
- Lamotrigine (Lamictal): This medication is usually titrated up due to high incidence of serious rashes, so only load if the patient has been using continuously for > 6 months and has been off of it for less than 5 days. The dose is 6.5 mg/kg single oral load.
- Levetiracetam (Keppra): 1500 mg single oral or IV load. Doses up to 30-50 mg/kg IV can be used for status epilepticus with a maximum rate of 100 mg/minute.
- Phenytoin: 20 mg/kg oral load should be divided into maximum doses of 400 mg every 2 hours. 18 mg/kg is the suggested IV load with a maximum rate of 50 mg/min in adults. IV is faster, but carries more side effects, and the evidence shows that there is no advantage of either route in terms of seizure recurrence. For status, you may increase the dose to 30 mg/kg total.
- Fosphenytoin: 18 PE (phenytoin equivalents) per kg total IV load at max rate of 150 PE/minute. This can also be given IM.
- Valproate: 20-30 mg/kg IV load at maximum rate of 10 mg/minute. The rate can be increased to 40 mg/minute in status.
To summarize, controlling ongoing seizures is essential. Be sure you are searching for treatable causes of seizure activity, and address those promptly. Initial treatment for status epilepticus is optimal doses of benzodiazepines. If that isn’t successful, there are a variety of medications available, so pick one and treat aggressively with multiple medications until control is achieved.
It is educational to review the details in the policy (see link below). Please let me know if you have any questions or comments.
ED Medical Director at California Hospital Medical Center, Los Angeles, CA
Member of VEP Board of Directors
marcfuternick@aol.com
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Excellent Mnemonic For Treating Critically Ill Patients In The ED
Dear Providers,
The following link takes you to an excellent 10 minute video that expands on the routine ABCs:
http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/46846
The video is summarized in the article below which has multiple links to very good online resources. The video and article are from Reuben Strayer, MD, Assistant Clinical Professor of Emergency Medicine at Mount Sinai Hospital in New York City.
I hope you enjoy it.
Robert Wyman, MD
Vice President of Quality
rwyman@vephealthcare.com
Resuscitation in the ED: Beyond the ABCs
Approaching a critically ill patient can be nerve-racking, and when your nerves are racked it can be hard to remember what to do. However, when you remember what to do, your nerves get less racked. So, I’m going to present a top-down approach to resuscitation that uses an expanded ABC’s mnemonic to jog your memory and unrack your nerves:
DC3, A through J
For many years now, I go through this sequence in my head every time I’m confronted with a critically ill patent, and it makes me calm and organized, and a better doctor.
D for Danger
Danger to you the provider. Is it safe to approach the patient? In the emergency department this usually means protecting yourself from body fluid or airborne infectious diseases. Occasionally, there may be other concerns like the patient having something dangerous on their clothes or skin requiring decontamination. We deal with agitated or potentially violent patients all the time. Like many of these bullet points, this is a talk unto itself, but from the perspective of resuscitation, if a critically ill patient is too agitated to be properly assessed, it is an absolutely crucial lifesaving maneuver to immediately and aggressively sedate. There are a variety of effective agents I recommend: Droperidol, midazolam, and ketamine. If an IV is not yet available the agents should be given IM or IO.
C3
The first C in C3 is “Call for help,” move the patient to resus, call for your defibrillator, crash cart, airway cart, or whatever else is indicated. In big centers, you generally want more nurses and tech than usually show up and fewer doctors than usually show up.
Now that everyone is in the room you have to get them to be quiet. The second C is “Calm.” Noise and shouting raise the ambient catecholamine level which makes it harder to take care of the patient. A forceful “Quiet please!” is usually all that’s necessary to take everyone down a few notches. In big centers, there are usually too many people in the resus room when the patient arrives. Big resus cases are good for learning and occasionally someone in the peanut gallery has a good idea — occasionally — so I don’t like to ask folks to leave the room.
Get them away from the action by announcing something like, “If you are not directly taking care of the patient please move to the perimeter of the room.” If there is an orthopedist hanging out, he won’t know the word “perimeter,” so try “Please move away from the bed.”
This is the time to determine who the resus leader is; if you’re not sure, maybe it’s you. All right, now that we’ve established the conditions in which the patient can be properly resuscitated, it’s time to resuscitate the patient.
The third C in C3 stands for “Cardiac Arrest.” Cardiac arrest has to be recognized straight away and is surprisingly easy to miss especially in a patient who arrives intubated by EMS. The first two priorities in cardiac arrest are immediate uninterrupted high-quality chest compressions and defibrillation of v-fib and pulseless v-tach.
Cardinal ABCs
Now, we start in with the cardinal ABCs and A is of course “Airway.” Our question is whether the patient needs an airway intervention. To answer this question, start with the patient’s voice. The patient speaking comfortably with a normal voice is very unlikely to require an airway maneuver in the immediate term. Patients who are not speaking, demonstrate a patent and defended airway by handling their secretions.
Drooling and gurgling, coughing and gagging, are your clue that you may have an airway problem. But do not elicit a gag reflex as a way to test airway integrity. It’s inaccurate and may induce vomiting and is exactly the person you do not want to vomit. Stridor is another sign and patients with a good level of consciousness and an airway obstruction may assume an airway posture, which is sniffing position.
Sometimes, the patient just needs repositioning of the head, but this is also the time to suction out the oropharynx, place oral or nasal airways or even an LMA if indicated, and determine if intubation is required or soon will be. If so, call for medications if needed and prepare for definitive airway management.
Move on to “Breathing,” which is oxygenation and ventilation. Do yourself and patients a favor and put a nasal cannula on every critically ill patient from the start and then any additional oxygen or ventilation on top of that. Unless the patient is truly crashing, I apply the nasal cannula and keep the wall-oxygen off until I get a room air oxygen saturation, which provides much more information about oxygenation and ventilation than a saturation with supplemental oxygen.
Ventilate the patient if needed. Your initial exam maneuvers are pulse oximetry, respiratory rate, effort, and then breath sounds. Auscultating the lungs is a reflex action taken by many junior clinicians as a response to a distressed patient. I think that’s because it makes it seem like you’re doing something when you don’t know what to do. In most cases, listening to the lungs is not helpful and is always less important than evaluating oxygenation and ventilation using respiratory effort and saturation. What you’re listening for is air entering both sides, and the presence of wheezes or crackles. This should take no longer than seven second — 3.5 seconds per lung.
Therapies to consider in the first five minutes relevant to breathing include needle finger or tube or ostomy, albuterol, epinephrine, or nitro. Call for a portable chest x-ray if indicated.
The initial “Circulation” priorities include immediate establishment of either intravenous or intraosseous access, measurement of heart rate and blood pressure, which is usually accomplished by putting a patient on a monitor, and the assessment of the adequacy of perfusion, feel for pulses, and assess the skin at the hands and feet. Immediate therapies to support circulation include IV fluids and uncrossed matched blood products and call for EKG when indicated.
Hyperkalemia is so common and so dangerous it should specifically be considered in a primary survey. C can also stand for “Calcium” in a critically ill dialysis patient with bradycardia or a wide complex rhythm.
D for Neurologic Disability
In the first phase of resuscitation, this calls for four maneuvers. Assessment of level of consciousness, usually using a responsiveness scale like GCS as well as the quality of the patient’s mentation. Agitation or confusion are as important as decreased consciousness. Measure the pupils and their response to light. Determine movement at four extremities and rule out or treat hyperglycemia.
We don’t have a problem with getting to do head CTs, but to be complete I must mention that this is the time to consider a STAT brain scan.
E for Exposure
Remove all clothing. And visualize every inch of skin. It is ideal if you can get this done at the initial assessment. It really sucks when the ICU team comes down and pulls the nitro patch off your hypotensive patient. Have someone check the pocket for pill bottles, the pacemaker wallet card, or a summary of their medical history. Use the opportunity to do a rectal temp if needed, and initiate active cooling or warming if indicated.
F Stands for Family and friends
If the history isn’t clear, get a better story. Ask about goals of care, if appropriate. Give the patient’s family an update on a patient’s status within a cautious prognosis. If you say, “I’m very concerned about grandma,” and she does well that’s not a big problem. In fact, it makes you look like a very skillful doctor. If you say, “Grandma is doing great,” and the next time the family sees her they have to unzip a body bag, you’re not going to get a rave review on Healthgrades.com. If the family is outside the resus area, ask them if they wish to be present during the resuscitation.
G Is for Analgesia
Do not forget to treat your patient’s pain. I have looked back at many resuscitations and realized the only thing I did that actually helped the patient was morphine. Give it early and in appropriate doses: IV, IM or IO. If hypertension is a concern use fentanyl. If you don’t have a line in a child, intranasal fentanyl is very effective. And for the patient in severe pain, adding an analgesic dose of ketamine is magic.
H Is for HCG
This is easy to forget and pregnancy changes everything. The bedside urine HCG assay works just as well with two drops of whole blood or capillary blood from a finger stick. In the clearly gravid female who is hypotensive, push the uterus to the left, And if she is dying or dead, consider a perimortem C-section. Don’t worry about how many weeks or how many minutes mom has been arrested — perimortem cesarean section is for mom more than for baby.
I Is for Infection
Consider whether the patient should be isolated, and do not delay the administration of broad spectrum antibiotics in a patient thought to be critically ill from an infection. If source control is required, this needs to be done expeditiously.
J Is for Ultrasound Jel The last part of the first 5 minutes is ultrasound. Let me know if you have a better way of getting the word ultrasound to work with the letter J. All patients with hypotension of unclear etiology should have a comprehensive point of care ultrasound for shock. There is an ever expanding list of indications of point of care ultrasound. Get the probe on the chest early in a critically ill patient.
There is another C I left out: If you are using a mnemonic to study for oral board exams, add one more C after Cardiac Arrest — as in C for spine immobilization collars. These have minimal if any utility in few, if any patients, and certainly cause harm, but we’re probably a long way away from standard of care catching up to science in this domain. So if you’re resuscitating a patient while wearing your best suit seated uncomfortably in a hotel across from somebody with gray hair who doesn’t want to be there any more than you, add a C for C spine precautions.
In real life for the first 5 minutes of resuscitation: DC3, A through J.
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