Where to for Emergency Medicine? What model of care do we want?

I am always left a bit flummoxed by exhortations to dream up a new model of care for the ED. I feel as though the person doing the exhorting has some specific image in their head that they are hoping everyone else might share but I can never quite work out what it is.

The traditional model that I grew up into was that people decided what constituted an emergency themselves and either called an Ambulance or walked in to the ED and the triage system rewarded those who had what we agreed was an emergency by giving them prompt treatment, while punishing those who we disagreed with by banishing them to the waiting room. As demand went up it became normal for those banished to the waiting room to wait for 4, 5 or 6 hours, with stories of people waiting 24 hours to be treated being possibly true or possibly urban myth.Then we started to get the patients who even we thought had an emergency waiting hours. Bed block bypass, ambulance ramping. Something wasn’t working.

It wasn’t long before that started getting taken apart though. Part-way through my second post-grad year the Victorian trauma system was born. Along with the redirection of most of the trauma to the major trauma services, it was also heralded the arrival of the formal trauma team model in our urban district emergency department. Suddenly, while an ATS category 2 stroke or chest pain could theoretically wait 10 minutes to be seen (and would sometimes wait much longer unfortunately), a Cat 2 trauma was being seen by a multidisciplinary team immediately.

Then came the fast-track. My training hospital was already running an “Acute Care” side and an “Injury Clinic” side reasonably successfully. Fast Track took this idea into a lot more EDs. There is no doubt that Fast Track eases the waiting room and allows efficient care to be provided to the kind of people who are hard to take care of outside the ED (cut, sprained and broken things that need some imaging and a simple fix) but it also has the potential to prioritise the sore finger over the septic abdomen simply because the Fast Track side of the ED is actually flowing and the main side is blocked up.

Now we have Code Stroke, Code STEMI, Trauma, Sepsis, Neonates all competing for immediate care. What’s more, nobody else wants to wait to be seen either. People are talking about the wait-free-ED. A previous Prime Minister of Australia decided that no patient should stay in ED longer than 4 hours and although that is about the length of time an Australian Prime Minister currently stays in office, the 4 hour rule has stuck, for better or for worse. Short stay units, acute medical units, clinical decision making units have all changed the way we move patients out of the department.

And the patients still wait too long to be seen.

There are a lot of EDs in the US and Australia that have attempted to get rid of their waiting rooms and that have created discharge lounges and results lounges and various similar spaces, attempting to shift the waiting process to the end of the stay rather than the beginning. I have seen a lot where the results/discharge lounges are being used for equipment storage and they have stuck temporary seating in next to triage to accommodate the waiting patients now that there is no waiting room. In others, the resus patients are sieved off to one side and the fast track patients sieved off to the other. The remainder are seen at the front door by a team lead by a (frequently disgruntled) emergency physician and then… well they wait of course. Because these remain the bulk of the patients. The fact that we have sieved off all the easy ones into categories with individual names doesn’t change the fact that the undifferentiated maybe-sick-maybe-not patient is the bulk of the ED census. They are also the bulk of the hospital admissions.

So does this mean the only way to see everyone straight away is for the EP to run faster? Because that doesn’t sound like innovation to me.

In order to try and rebuild the way we practice emergency medicine we really need to think about what the role of the ED is and what we want our specialty to do. We definitely need to do more than demolish the waiting room.

Why do we need EDs?

First of all, we would all agree that the community needs a place where critically ill patients can be rescued at any time of the day or night, every day of the year, by doctors and nurses experienced in resuscitation.

Resus however is not really why Emergency Medicine was born. Essentially EM came to be because there were patients who either needed to be admitted to the hospital acutely, or who were worried that they might need to be, and the way these patients were being treated was an embarrassment and medico-legal liability for the hospital. Junior doctors, inadequate equipment, poor supervision were the standard way to access the hospital system if you became ill or injured in such a way that you weren’t able to come via an experienced doctor’s rooms.

Since establishing the role of EM as a gateway to the hospital for unscheduled care, and as a resuscitation unit, the mission has progressively expanded, to providing a form of acute primary care for ambulant patients, acute psychiatric care, a screening service for all acute hospital admissions even those coming from the rooms of the admitting physician, a minor injuries service, a second opinion service, a proxy outpatients service and so on.

What do we want an Emergency Physician to be?

Here are some ideas that I have about how we might rejig our work, based around the different faces of the FACEM community. I don’t really know how it would all operate, I just have some ideas about the different kinds of EM practice that might exist and ways that we might like to stream our patients along those lines to get the best for all of them.

The critical care EP

This FACEM would happily just run a 5 -10 bed resus room with 3 ED-ICU short stay beds and a 10 bed Short stay (nursed at 1:3 – 1:4 night and day) and never see a weak and dizzy or a back pain or a broken arm unless their FastTrack colleague was bringing them a broken arm patient to sedate/anaesthetise for a manipulation and plaster. They would see chest pain, sepsis, COPD, pneumonia, trauma, acute heads, and nothing much else. Running a no-wait system would be straightforward in this area. You need a registrar, an intern and a final year med student to run this unit and the EP, when nothing is happening, would be working on writing a paper about what a great job they’ve got.

There are some amongst us who would be very happy in this role and would be delighted for this to be the totality of Emergency Medicine. There are some troubles with this system however. First, there isn’t enough work for all the EPs out there. Second, there will be the problem of over and under triage. There is still going to need to be a place for all the people who don’t immediately seem like they belong in the ED-ICU but who might turn out that way, unless you want to really overtriage into the ED-ICU in which case you have just reproduced the current ED.

Which brings us to…

The needle in the haystack EP

This doc takes care of the biggest group of ED patients. These are the triage Category 3 and 4 patients, none of whom have simple binary questions to answer and many of whom end up needing admission to hospital.

This EP’s main tool with a critically ill patient is the ability to recognise them and send them to the right place. Their greater strength is in taking care of all the weak, wobbly, tired, dizzy, frightened, puffy ankled, short of breath, belly aching, more confused that usual, pregnant and bleeding, muddled-up-my-tablets patients that occupy the the mass of our cubicles away from resus. They can make people feel listened to and cared for and can find the sick patients without putting the whole ED census through a CT scanner.

Running a no-wait system for the needle in the haystack EP’s patients is a very challenging notion. The problems they present with do not truly justify no-wait; providing a top notch no-wait service for them is potentially taking business away from the GPs (and in Australia, where the government runs the hospitals but the GPs are operating in a private practice model, there are issues with “big government” stealing customers from “the little guy”). The better this service is the more it will creep into less and less emergent problems because people will choose it over the GP who costs money and can’t get everything done on site in one visit.

A more efficient system for these patients could start with patients not owning a bed but lying down for a purpose. It is mad that someone who is not incapacitated should be tucked up in bed in the middle of the day while a sick person doesn’t see a doctor for lack of somewhere to be seen. So get the patient into a gown and onto a trolley. Take the story and examine them, get the ECG, bloods and imaging.Then get them out of their ED trolley and somewhere else and free up the acute assessment space for someone else.

These are the patients who might be more efficiently managed using a results lounge or discharge lounge or some arm chairs. The Needle in the haystack EP needs to use their beds like a consultation space, to speak to and examine patients and then stream them to somewhere else (straight home, SSOU- like area, resus-critical care area). The needle in a haystack EP probably needs a different sort of SSOU from the critcare EP.

What are the barriers to these systems being used?

Patient gowns
Once you are in a gown you want to be in a bed because otherwise the world can see your arse. We need to rethink how we dress/undress our patients if we want to use a “return to waiting room” strategy. Surely we can do better than those awful gowns.
IVs:
We probably place a lot of unnecessary IVs and we give a lot of unecessary IV fluid but having an IV up will stop someone moving out of their trolley. If there is a need to use IV therapy or meds in a non-critical care environment we should probably stream those patients off to a short stay unit (although the fact that people can have IV infusions of horrendous poisons whilst sitting in armchairs in day oncology suggests that we don’t strictly need a patient to be lying on a trolley just to have an IV medication.
Monitoring:
Don’t we just love monitoring? And don’t the patients hate it, especially the horrible NIBP cuff that brutalises their arm every 15 minutes. We need to think more rationally about monitoring. The patients requiring ongoing monitoring and obs should be streamed into the resus-critcare ED or the SSOU.
Patients are tricky:
As much as we make a thing of EPs being able to make a split second decision and predict where the patient is going, the truth is that only works most of the time. We still get screwed often enough that the quick look/superficial front door assessment can get us into trouble. The primary care EP is most at risk from this because they treat the large numbers of haystack patients. The patients triaged to the critical care ED are assumed to be sick so the critcare EP starts by throwing everything at them and gradually trims back. The patients in the primary care ED are assumed to be not so sick and so will catch us out sometimes. There needs to be a good system for moving back from SSOU if things are not right with these patients without it being punitive. It needs to be accepted that we are putting some patients into SSOU in order to let them declare themselves as sick or well.

The bumps and breaks EP:

Fast track is working pretty well for us. There are lots of models that work well with this. In the US is is almost all run by Nurse Practitioners and Physician’s Assistants. At our place it is supervised by a FACEM or registrar but the bulk of the work falls to the intern and physiotherapist (and our one and only NP when she is on shift). I like the idea of medical involvement in FT as it provides a good training ground in surgical and orthopedic skills and it can be satisfying work. It seems a shame to hand it all over to another profession.

The ongoing care EP:

There are some of us who really enjoy the ongoing care side of medicine and are a bit misplaced in the 4 hour ED. We need to think about how to keep a role for ourselves in the 4 hour rule world. I think we need to look at what we are good at: decision making, working with different people, coordinating and keeping up a good tempo of work at 24/7/365. As the 4 hour rule shrinks the Emergency Physician’s domain, the EP needs to look at new territories to conquer.

Departments of Emergency Medicine need to look hard at whether they could take over Hospital in the Home, “frequent flyer programs” (HARP in Victoria), Residential Care In-reach programs and Telemedicine programs. Innovative staffing solutions including nurse practitioners, paramedics, physician home visits should all be considered. In Montreal, I am told, it is common for family medicine residents to share an oncall service for assessment of nursing home patients, a centre in Pittsburgh is using paramedics to do home visits for their admission reduction program, in Bendigo we use an experienced nurse who can consult with the Geriatrician and Emergency Physician on call, to do nursing home visits and to support their staff with acutely unwell patients.

Further than this, EM should be looking at whether we are the people to run clinical decision making units, acute medical units, even acute surgical assessment units. These would be a big reach from where we currently sit but I don’t believe they are out of our reach. Our tempo of work suits these units. Taking our skills into these units would mean that we were not taking patients who really needed the attention of an EP and sending them prematurely on to an internal medicine physician or a surgeon just to satisfy a mandate to get patients off ED trolleys in 4 hours.

It is likely that a shared care model would be required. The ultimate decision on a surgical decision making unit is when to take a patient to the operating theatre, a decision which is the domain of someone who will be operating on them.Acute medical units, while mostly managing common conditions in a fairly standard way, are a place that the more esoteric diagnoses need to be explored, and the complexities of interacting comorbidities carefully considered. This is the domain of the internal medicine physician.

In each of these units, an EP could  use their expertise in managing the flow of patients and coordination of care, and applying their familiarity with rapid turnaround times and frequent revision of plans, hand in hand with the surgeon or physician (internist).

This kind of sharing of expertise is something I believe we are getting better and better at due to growing experience in the resus room as team leaders. In Australia, the UK and parts of Canada it is common for the EP to team lead trauma resuscitation with a trauma surgeon in attendance for their specific surgical expertise (this happens less in the US where trauma surgeons spend a third of their life as intensivists and tend to combine the jobs of resuscitationist and surgeon). In our hospital we are working hard on taking a similar approach to Neonatal Resuscitation, this time sharing care with the general paediatritian (we have no neonatologists in regional Australia). Anyone who has done a pre-hospital physician role will be familiar with the process of sharing care and expertise with an intensive care paramedic. As we all get better at understanding that we are all working to the same end we (we being the health care provider world in general) we will get better and better a this process.

The front door EP

I don’t even want to talk about the front door job. I think we made a big mistake by stressing that we can usually make a decision in a few minutes because now there are places that are expecting us to do that, accurately, every few minutes for a 9 hours shift, with no ongoing connection with the patient and no chance to get feedback on those decisions. I am yet to meet an EP who, when asked about the front door role, doesn’t roll their eyes and groan (except a few directors who speak expansively about the wonderful effects on ED wait times).

In summary

Emergency Medicine has come so far since its birth in the 1960s, too far for us to allow it to be defined out of existence by changes to KPIs from above. Luckily for Emergency Medicine, we remain a new specialty which means optimism, agility and a preparedness to adapt and develop. What we need is passionate and imaginative Emergency Medicine innovators prepared to try new things to get good results for our patients and the community and to further develop our specialty.

We are not short on such people.

Neonatal resuscitation and the emergency physician

Why should an Emergency Physician be competent at neonatal resus?

Isn’t it someone else’s job? Babies get delivered in theatre or labour ward don’t they? WRONG- this paper from a couple of decades ago showed one ED delivering about 1 baby a month with a high rate of maternal and fetal complications. If a baby is being delivered in your ED or in an ambulance something has gone wrong somewhere. It may be as simple as poor estimation of the time to get to hospital but it may be associated with lack of antenatal care, maternal illness or trauma or poor maternal self-care. If a lot of babies are being born in your ED you need to start looking at whether there is something wrong with your obstetrics and midwifery resources.

It still sounds like somebody else’s problem. Can’t I just call a neonatal code blue and go make a cup of tea?

You can do this if you like. Personally I think letting someone else run a resus in my resus room without me is like calling a babysitter over to separate my sons when they’re fighting. She will probably do a good job but how are the kids going to look at me afterward? When she disarms the eldest will she put his cricket bat away in the right place? Will she know where to look for the crowbar to lever them apart? This is your resus room, your nursing colleagues nursing the baby and your residents and registrars looking on and trying to learn. Are you really going to abdicate responsibility for the case? And who exactly is the neonatal team in your hospital? If you’re in a top level tertiary centre with a neonatal ICU you may have a very different neonatal team from what you have in a regional general hospital. The local paediatrician may be the content expert in the room but there are paediatricians who live for resuscitating sick kids and there are paediatricians who spend their days dealing with developmental delay, psychiatric illness, coughs and colds and autism and who enjoy a neonatal resus like they enjoy getting a root canal, just like there are emergency physicians who live for resus and others who can see 25 fractured NOFs and dizzy/giddies in a day and go home thinking they had the shift of their life. The model we are trying to work toward in Bendigo ED is a collaborative one where the emergency physician and paediatrician work together to run neonatal resuscitations that occur in ED. Now this is an approach that requires a degree of trust on both sides and excellent communication but if emergency physicians and trauma surgeons can sort this stuff out (and they have done, in most places, by now) then so can emergency physicians and paediatricians.

Why is this important?

The neonatal resus team in a general hospital will likely include nurses from the Special Care Nursery and a paediatrician and paediatric registrar or resident. They will have considerable experience and expertise resuscitating newborns in labour ward and in theatre. Both of these environments are set up for them to carry out their routines in because they are there every day. Every day. The ED resus room is a place they come to as a team perhaps a few times a year and as individuals much less frequently. The equipment is not where they expect it to be. Everything is the wrong size. There is a drunk guy on their left swearing through the curtain. Worse still there are emergency physicians and emergency nurses everywhere, terrifying people who say bad words and seem comfortable in this horrible environment. If you are going to get the best out of this group of experts who have just come down to your ED you need to take charge of the room just like you have ben trained to do for every other crisis in ED. You need to make that team feel safe and wanted, you need to put them to work to solve your problem (the sick baby in your ED) and you need to integrate them into your own team.

No time for blogging now, the bat phone is ringing.

A 19 year old woman has just delivered a baby in the back of an ambulance. Mum seems unwell and has had no antenatal care. Bub is in poor condition. They are 4 minutes away.

How are you going to set up?

First of all, any extra information you can get now could be invaluable in a few minutes. Is the baby term? Is it breathing? Is there meconium? The likelihood is though that your information is coming second hand from ambulance control and you may not be able to get anything more. Resuscitating a flat neonate in ED is an uncommon thing so you want to be prepared. It makes sense to call your neonatal team now so that you have a chance of forming yourselves into a functioning team by the time the patient arrives. You need to call for the resuscitaire or find it and plug it in. In the absence of a resuscitaire you need some sort of firm, well lit surface with a source of heat and access to air, oxygen, pressure control and suction. You should identify your umbilical catheter pack and consider opening it. If your neonatal resus algorithm is not up in the wall then with luck it is laminated in the drawer of your resuscitaire. If not, print one off today and get it laminated.

Neonatal Resus Flowchart available in full size pdf from the ARC at Neonatal Resus Flowchart available in full size pdf from the ARC. https://resus.org.au/guidelines/flowcharts-3/

Neonatal Resus Flowchart available in full size pdf from the ARC.

Decision point 1: Has the baby started breathing yet?

The baby arrives. Remember that babies survive birth in massive numbers every day. The one critical thing the baby needs to do to make the transition from uterine to terrestrial life is to take a breath. So before you do anything else, look at the baby: is it crying (and therefore breathing) and wriggling or is it floppy and silent. If it is crying and wriggling it is exceedingly unlikely that you need to do anything further for it. If it is floppy and silent however then you need to give it some help.

Decision point 2: Is there meconium?

The next decision point is whether the baby is covered in sticky green/black/yellowy muck. Like most resus, neonatal resus has become simpler over the years. There used to be all sorts of complex decisions to make about meconium. Now, if the baby has not breathed and there is thick meconium, airway toilet comes before everything else. If the baby is already breathing, or if there is no mec, then you pretty much just follow the flowchart above.

Decision point 3: Is the baby very premature?

Now is not the time for a full assessment of gestational age but if the baby looks very premature you need to protect it from the environment fairly quickly. Very premature babies are not waterproof yet and will quickly run into trouble with heat and water loss through their skin. Current recommendations here are to cut a hole in the bottom of a zip-lock bag, big enough for the head to pass through and then put the baby in the bag with the head poking out and the big opening zipped up. Procedures may require further holes to be made in the bag to admit limbs or the umbilical cord. Some sort of hat or other covering should be put on the head of the baby. If the baby is very premature it is important to remember that very premature babies born outside of tertiary centres have an extremely low survival rate.

Proceeding through the algorithm.

Your baby is floppy, pale and not breathing. There is no meconium. It appears to be about term. It is time to get started on the algorithm. The great majority of babies will respond to the first steps of the algorithm and as you progress down it there is a diminishing return to be had from your efforts.

Before we go on, there are two things for the adult emergency physician to adjust to with the neonatal resus algorithm. The first is that it is all about ventilation, ventilation, ventilation rather than circulation (until it is not). The second is that each cycle of intervention-assessment-intervention should take 30 seconds only.

Step 1

Put the baby under the heat lamps and stimulate it (flick the feet, rub it a bit, blow on its face) while ensuring the airway is open by putting the head in a sniffing position. Some babies with small jaws (for example those with Pierre-Robin sequence where a cleft palate leads to a set back tongue and an under-grown mandible) will not have breathed because their upper airway is obstructed.

Most babies will respond to this. Yours hasn’t.

Step 2

Start some ventilation and get a sat probe and monitoring on. Start with 21% O2. Whether you ventilate with a self-inflating bag and PEEP valve or with an oxygen blending device like the Neo-Puff is up to you and your institution but I would strongly encourage getting to know the Neo-Puff if your resuscitaire is equipped with one. It will take you about 3 minutes of quiet time to get the hang of it. There is an inlet valve that is usually connected to an oxygen bottle and low volume flow meter attached to your resuscitaire, and an air blender attached to a medical air source. There is a knob to set the inspiratory pressure (default to 30 but be prepared to turn it up for the first few breaths), another knob with a “don’t-mess-with-this-knob” cover over it which sets the pop-off pressure (to guard against transient pressure rises above the set PIP, say when CPR is going on) and on the end of the circuit there is an adjustable PEEP valve which you occlude with your finger to create IPAP and which you release again to create EPAP. There is no on-switch because it is just a set of valves and gas pipes. To read more about the neopuff, check out this blogpost by Rick Frea, a respiratory therapist from Michigan.

Aim for about 60 breaths a minute counting a fast waltz in your head (1-2-3, 1-2-3, 1-2-3) and allowing inspiration on the “1” and expiration on the “2-3”.

Having started off the business of respiration most babies will again respond at this stage. Yours hasn’t.

Step 3.

Now we should have a heart rate available from the sat probe. We are looking for a good fast heart rate (well over 100) to reassure us that things are going well. If it is below 100 take steps to improve the quality of your ventilation. Reposition the airway, increase the PIP and provide some oxygen. If it is agonal or extremely slow at this point you may wish to start CPR early but the algorithm emphasises improving the ventilation as a first step. You may also wish to intubate the baby at this point if you have the skills although in the short term, face mask ventilation is usually quite adequate. Laryngeal mask airways may be a worthwhile investment for your ED if you think people are going to be reluctant to intubate a neonate.

Step 4.

Reassess the HR (in reality you have been watching it on the sat probe the whole time). If it above 60 keep doing what you are doing until it gets above 100 and then go on to post-resus care. If it is below 60 it is time to start CPR. You need to abandon your fast waltz because now the rhythm is that of the conga-line. I like to think of the episode of The Simpsons when Lisa tried to serve salad at the neighbourhood barbecue hosted by her father and everyone except her ended up conga-line dancing around the yard chanting “you don’t win friends with salad, you don’t win friends with salad”. Normal people probably count something like “one and two and three and breathe, one and two and three and breathe” to get the 3-to-1 compression to breath ratio right but I prefer the Simpsons.

Step 5.

Still less than 60? You need to get some IV/IO/UV access and give some adrenaline. Your kid is pale which should trigger you to think of ante-partum haemorrhage and hypovolaemia so a fluid bolus is indicated. Babies normally come out a horrible blue colour and become sort of bright red so a pale kid is not normal. Remember that the baby has spent the last 9 months in an environment about as well oxygenated as the top of Mt Everest. It should have a Hb of around 180g/L.

Intubating neonates.

  • This is something you need to learn by doing on a mannikin and not from a blogpost but here are some basic tips for the person trained to intubate larger humans.
  • The distance to the larynx is much shorter than you are used to. If you just see a big whole you are holding a rigid oesophagoscope. Turn it into a laryngoscope by withdrawing it gently.
  • Neonates are softer and more delicate than large humans. You can’t jam that laryngoscope in in the way you do to an adult and if you lift it with the kind of force you are used to applying in large adults you risk completing a mandibulectomy. Practice a few times on a good quality neonatal mannikin and you will get a feel for it. Also, your introducer, if you are using one, must not protrude beyond the end of the tube as it can easily puncture the trachea.
  • The larynx is more anterior than you are used to. Cricoid or some variant on it will always be helpful to bring it into view.
  • The epiglottis is larger and more troublesome. You may end up just picking it up with the tip of the blade (one of the reasons a straight Miller blade is helpful) to get it out of the way.

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Umbilical Catheterisation.

The umbilical cord in the first hours of life offers you one of the easiest IV access opportunities you will ever get but you don’t want to learn the technique on the day. The NEJM has a magnificent video on Umbi vein catheterisation but it is paywalled for subscribers. Try to get access to it if you can, it is very well done.

Here is our umber vein kit opened. It looks to me to be a bit more than you really want for urgent umbilical vein access.

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We are looking at trimming it down to what you actually need which is more like this.IMG_2545

The first thing to do is to get a nice clean cut across the umbilical cord with a scalpel like so. You are cutting it down to within a cm or so of the skin.IMG_2542

The next trick is to identify the single umbilical vein and the two umbilical arteries. Do not expect them to be spurting. In the picture below the vein is on the left and the two arteries are on the right. The NEJM vid talks about using a sterile tie to hold the base of the cord. An alternative, as shown in this picture, is to hold the slippery cord with some dry gauze. IMG_2540

You need to dilate the vein a little with the very fine mosquito forceps. Then take your catheter and insert it into the vein to a depth of about 5cm. In a semi-elective setting these can be put much further in, acting as central lines, but in the emergency there is no way to know that the tip is not in the hepatic veins if pushed in more than 5 cm so we keep it a bit more shallow.

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Ventilating a neonate

The volumes you want to use are small. This means you cannot just pop on the oxylog and turn the dials down low. The ratio of dead space to ventilation and the ratio of variability to volume is just too great with an adult machine. You will need to call SCBU to get the neonatal ventilator down. Here are some starting numbers for ventilating a neonate:

  • Ti 0.4 sec
  • RR 60
  • IPAP 25
  • PEEP 5

Aim to achieve:

  • MV of 0.25-0.4L/kg/min
  • Spo2 85-95% in a preterm baby and 90-95% in a term baby
  • Tolerating an ETCO2 of 60mmHg.

After ABC comes DEFG: Don’t Ever Forget Glucose

Neonates have very little energy storage available.

Give 2mL/kg of 10% if hypoglycaemic.

What about drugs and doses and volumes. I can’t remember!!

Don’t try. This book, prepared by Dr Simon Craig and colleagues at Monash Children’s Emergency Department is available online and a fantastic resource for people who take care of sick kids. Every page opens to a different weight (in half kg increments in smaller kids and 1kg increments as they get bigger) and gives doses for everything from IM adrenaline for anaphylaxis to prostaglandin for a closing Ductus in congenital heart disease.

Enormous Thank You!!

Thanks to our teachers Dr Martina Moorkamp, Neonatologist from The Mercy Hospital in Melbourne and Dr Preeti Ramaswamy, our brand new Paediatric emergency physician at Bendigo for preparing the extraordinary day of neonatal education for us which allowed me to prepare this post.IMG_2529

Aliem’s “Dirty Epi Drip”- I’m a convert

FOAM readers will have come across Michelle Lin and her Academic Life in Emergency Medicine blog and Tricks of the Trade spot on EMRAP. Recently she has been spruiking the “Dirty Epi” drip in anaphylaxis.

The idea is, when the patient fails to respond to two IM doses of adrenaline and you are looking at switching to IV everything is usually happening pretty fast. You really want that adrenaline up now, not in 5-7 minutes time, which is what it can take for a 6mg in 100mL to be made up and countersigned and a pump found and so on. So, while the nurses are scrambling for that, put 1mg of Adrenaline of any concentration into the bag of Normal Saline that has likely just been hung and just let it run in, titrating to effect. It will give 1mcg/mL and will run at about 20-30mL/min so you’ll be giving 20-30mcg/min which is a pretty good starting dose for IV adrenaline in refractory anaphylactic shock. Of course, you might have to titrate to effect by tightening up the little roller clamp or squeezing the bag but you titrate an adrenaline infusion to effect anyway.

The trouble is, how often do we see refractory anaphylaxis? So I read about it and thought, well, that’s great but I’m not going to use it.

Then comes the middle aged, not terribly well preserved man with hyponatraemia of uncertain cause, left lower lobe pneumonia, septic shock and respiratory failure who needs a tube. BP falling just as the need to get on and intubate becomes apparent. No pressors up yet. Arterial line quickly inserted shows BP 60/20. Bother, that’s a bit lower than the NIBP was showing. This looks like a perfect opportunity for one of Scott Weingart’s Haemodynamic Kills. No time for a formal pressor infusion to be drawn up. I pull out a milligram of adrenaline to make up some dilute “push dose pressor” and a little voice in my head says “try the dirty epi drip”. There’s a full bag of fluid just been hung, running into a good ACF vein via an 18g cannula. Perfect.

With the arterial line in it was a piece of cake to titrate the flow of adrenaline-saline with the roller valve while keeping an eye on the registrar’s intubation and the resident’s (frugal) dosing of induction agents. To get the BP up initially required a couple of squeezes of the hand pump on the resus giving set but the BP quickly came up to where I wanted it (120/70 ish) and never dropped below 90/60 for the duration of the intubation process.

I actually think it is safer than fiddling around calculating concentrations and doses for “push dose” adrenaline, a process that carries a high risk of giving too much by a factor of 10. The main caveat would be that you need to be prepared to run in a litre of fluid. If your patient is shocked and being intubated a litre is probably neither here nor there but there may be cases where you really couldn’t afford the volume.

For now though, I’m a convert. Thanks Michelle!

PS: I should add, this is a hands-on activity. You can’t make one of these up, set it running and go do something else. Consider it a big syringe full of dilute drug. Once the dust settles, take it down and replace it with something you can run hands free though a pump.

They’re not dead until they’re warm and dead? Ceasing resuscitation in drownings.

I’m afraid this is a bit of a less cheery post than usual and it goes against the FOAMed grain of resuscitating everything regardless of likely outcome. But hey, my post on breaking bad news  seems to have become a late hit so perhaps cheery is not in this season.

So, it is late February, the temperature outside is 39 degrees Celsius, (for our northern colleagues, that is summertime down here and hot) and your ED is full of bruised cricketers, boozy barbequers, overheated grandmothers and sunburnt teenagers when the ambulance deliver you an 18 month old baby girl in cardiac arrest. She was not seen by anyone for perhaps an hour until a family member spotted her in the family swimming pool.

On arrival in ED the patient is in PEA arrest with no spontaneous respiratory activity and an initial temperature of 25.7 degrees.

Because of the tender age of the victim you continue to cycle through your arrest protocol for 60 minutes at the end of which the child is asystolic.

You are about to call it a day when someone pipes up with the old chestnut “you’re not dead until you’re warm and dead”.

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