Trip to Atlanta for SAEM conference

 

I returned in the early hours of this morning from my trip to Atlanta, Georgia for the 2013 Society of Academic Emergency Medicine (SAEM) Annual Meeting. I presented findings from research I have been doing with my EM research group. My topic was atrial fibrillation/flutter in the ED and patient quality of life. It was an amazing privilege to be able to attend this conference! I learned about the work that a lot of accomplished emergency physicians have been doing to improve patient care in the field. I also noticed that women are a minority in EM. This is something I was already aware of, but it became really evident when I noticed the gender variation among 100s of attendees. I’m not sure if I would like to pursue EM as a specialty, but it’s being considered!

I attended four didactic presentations. Here they are below, along with a few things I picked up from each talk. I sought out the pediatric-related lectures because I’m interested in Peds! (PEM = pediatric emergency medicine)

1. Harnessing the Emergency Medicine Perspective: Emphasizing Key Differences between Adult and Pediatric Chief Complaints to Enhance Residence Training in Pediatric Emergency Medicine

• EM & PEM docs manage critical patients similarly, but not non-critical patients.
• Essence of PEM (for the non-critical patient): do less.
• Ped abdominal pain ~ adult chest pain. Time-sensitive conditions such as malrotation, hernia, and intussusception are like adult STEMIs (meaning they are extremely urgent!). Appendicitis is like an NSTEMI. Constipation is like costochondritis (common complaint, not serious).
• Need a sense of urgency for ped abdominal emergencies, like volvulus.
• Ped chest pain ~ adult back pain. Most chest pain in kids does not require excess workup.
• Ped fever ~ elderly adult abdominal pain. General EM docs tend to overwork patients, causing them to stay longer in the dept.
• EM docs need to be taught literature pertaining to ped imaging (ultrasound vs. CT).
• Appreciate the importance of follow-up in ped patients. Remember that pediatricians are their advocates and will want to help you care for them.
• Hydration status is virtually a vital sign in children. Oral rehydration therapy is done by PEM docs more than EM docs.
• For pain and sedation in children, consider intranasal meds such as midazolam vs. hard ketamine/propofol. Sucrose works for doing lumbar punctures on neonates. Also, swaddling a child or having them sit on their mother’s lap can be effective.
• Bottom line: kids are healthy, be less invasive, kids don’t need a lot of intervention (labs & x-rays).
• During residency for general EM docs, stress highest yield ped ambulatory topics in integrated fashion with general EM.
• Use clinical pathways in ped patients, get rid of wide variabilities in their care.

2. The Great Pediatric Sedation Debate

• Ketamine can be used as a single agent in procedural sedation because it is both an analgesic and an anesthetic. It can cause nystagmus (the appearance of being awake). It is good for fracture reductions, and orthopedists like it a lot.
• Propofol is great for electrical cardioversion (in adults). It is a moderate to deep sedative that requires full cardiac monitoring. Quick onset and recovery. No analgesia. Used for normotensive patients undergoing quick, non-painful procedures. Will need a second agent for a painful procedure.
• When using an IV opioid + benzodiazepine (such as fentanyl and midazolam) sometimes you can overdose the ped patient inadvertently. You keep dosing the patient in order to alleviate their pain, but after you perform say, a fracture reduction, and the painful stimulus to breathe is gone (the patient becomes drowsy and non-responsive), you will need to administer the benzodiazepine antidote Flumazenil in order to reverse the sedative.
• EMLA is a topical anesthetic that can promote drainage for abscesses.
• LET (lidocaine, epinephrine, tetracaine) topical gel for local anesthesia.
• Intranasal midazolam for laceration repair.
• Children control pain well when distracted, so might not need sedation beyond effective local anesthesia. EM depts should consider investing in an ipad for ped patients!

3. Diagnostic Imaging and Radiation Exposure: How Much is Too Much?

• Does increased CT utilization lead to better care? Unclear.
• Negatives for kids: costs, length of stay, risks of contrast, sedation for children.
• Exposure to radiation in childhood means greater risk of developing cancer. Children’s organs are more radiosensitive. Also due to their longer life expectancy, they have more time to develop cancer than adults do. Girls during puberty are especially susceptible to radiation to breasts and thyroid.
• CT radiation dose needs to be dialed down for kids! Also, in general, patients should be imaged (given radiation doses) according to what is appropriate for their size. This isn’t done enough.
• Note that although we know how much radiation a CT machine puts out, we can’t measure what an individual patient is absorbing.
• Side note: Millimeter wave scanners at the airport do not emit xrays, the backscatter ones do. You would have to go through a backscatter scanner 600 times in order to get the same dose as you would from one chest x-ray (0.1mSv). The scanner is safe for pregnant women and children.
• Several campaigns to minimize radiation dosing: Image Gently, Choosing Wisely.
• Consider having your hospital accredited as part of these campaigns by doing phantom dose testing on your scanners to test radiation dose output.
• Consider promoting imaging history cards for patients so they can keep a record of procedures done.
• Clinical decision support for clinicians can help minimize radiation exposure.
• Validated decision rules have the potential to decrease unnecessary imaging.
• Radiologyinfo.org

4. Identifying the Value of Emergency Care in the Climate of Health Reform

• Health reform, Affordable Care Act (ACA)
• Value = health outcome / cost
• ED docs control 50% of all hospital admission decisions, and thus 30% of aggregate healthcare spending.
• Need better outpatient follow-up to reduce readmission rates.

I also saw some interesting posters, including one about the Canadian CT Head Rule in patients with minor head injury. There was also a “Visual Diagnosis” exhibit with photos and detailed case studies. I can’t wait until the day that I can actually understand them well!

Overall, it was a really fun trip and I’m happy to have had the experience! Atlanta is a nice place. I’ll leave you with this photo of an iron lung from my visit to the CDC museum yesterday…amazing that people actually had to be crammed into these things.