Tactical Medicine News Blog

Although there is much advice on helping new interns adjust to residency life (part 1, part 2), not much is shared about helping recent residency graduates survive the real world of EM practice. Dr. Amal Mattu, Professor and Vice Chair at the University of Maryland’s Department of Emergency Medicine, solicited for advice from his department’s faculty and recent residency graduates. Below are the top 15 themes which arose from the discussion and are frankly great reminders for all practitioners in the ED.

Venipuncture is the most common invasive procedure performed in the emergency department 1 , likely due to the fact that the vast majority of our laboratory evaluations require blood and many of our life saving interventions require access to the patient’s systemic circulation. Most of the time emergency department staff are able to perform this procedure easily, but occasionally you find that your patient is the dreaded “difficult stick”. Literature suggests that the landmark technique is successful on the initial venipuncture 74-77% of the time. 2–5  Success rates rise after multiple attempts, but what happens when you don’t have the luxury of time? What happens when your patient will die if you don’t get life saving medications into their circulation promptly?  There are a few options when you can’t get IV access through traditional means, among them external jugular vein cannulation, central line, ultrasound-guided IV, and the intraosseous lines (IO).6 However, when managing the crashing patient, a wise decision is to use the quickest option, which is often the IO.

Case: A 60 year old male presents after being hit by an automobile while riding his bicycle. He has significant blunt head trauma. His left eye is pictured here. What is the diagnosis?  

Background: In elderly patients on chronic anticoagulation (i.e. warfarin and clopidogrel), falls have been shown to increase the incidence of intracranial hemorrhage (ICH) versus those not on anticoagulation (8.0% vs 5.3%). Mortality in those with ICH on anticoagulation is also higher than those who are not (21.9% vs 15.2%). Patients >65 years of age account for almost 10% of ED visits and 30% of admissions for traumatic brain injury. Even more frustrating is clinical decision rules on who to scan and not scan (i.e. Canadian CT Head Rule, New Orleans Criteria, and NEXUS-II criteria) do not apply to anticoagulated patients, because these patients were excluded in many of these studies. To date studies on patients taking warfarin who suffer minor head injuries have shown an incidence of ICH from 6.2 – 29%, suggesting that physicians should have a low threshold to scan these patients. Finally, several European guidelines suggest that all anticoagulated patients with head trauma should be admitted for observation, even if the initial head CT is negative, based on limited data. Unfortunately, the risk of traumatic intracranial hemorrhage after blunt head trauma for patients on warfarin and clopidogrel, has never really been studied in a large generalizable cohort or under a rigorous, prospective, multicenter designed studies. Therefore, knowledge of the true prevalence and incidence of immediate and delayed traumatic ICH in patients on anticoagulation would allow for evidence based decisions to be made about initial patient evaluation and disposition instead of admitting all patients for observation for concern of delayed ICH [1].

This week, we have Dr. Erica Dance (@erdance), a wellness guru from the University of Alberta. Dr. Dance is a passionate individual, who loves discussing the topic of wellness. In her role as Assistant Dean she works in the Learner Advocacy and Wellness office to support the well-being of residents and fellows across her institution. Within the post, she shares her tips for how to make wellness part of your everyday routine. Check out how Dr. Dance stays healthy in EM!