First10EM Journal Club: August 2024

Welcome to another month of nerdy journal jam goodness. This month Justin has served up an eclectic collection of evidence, ethics and educational excellence. As always – we have the full PDFs liked below and you can read more deep thoughts over at First10EM where Justin likes to inconvenience a lot of electrons in his pursuit of educational elegance.

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In a surprise to no one who reads First10EM, clinical judgment is better than all decision tools for sepsis

Knack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med. 2024 Mar 25:S0196-0644(24)00099-4. doi: 10.1016/j.annemergmed.2024.02.009. Epub ahead of print. PMID: 38530675

Justin has written out his full thoughts here: First10Em – Gestalt,

Bottom line: These decision instruments for sepsis have never been shown to improve upon clinical judgement or improve patient care. Until we have evidence of benefit, they shouldn’t be used, and we should rely on clinical judgement, which this trial demonstrates is quite good. 

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Do you still suggest emergency medicine to your students?

Rosenberg H, Syed S, Atkinson P. CJEM debate series: #StillTheOne-while more challenging than ever, emergency medicine is still the best career path available for medical students. CJEM. 2024 Jun;26(6):381-385. doi: 10.1007/s43678-024-00682-8. Epub 2024 Apr 9. PMID: 38592662

Bottom line: Would you be happy if you kid follow-ed your footsteps into emergency medicine? I think it is important to be honest about the realities of our job for students considering the profession. We don’t do any favours by ‘selling’ the specialty. But I would still choose this path again for myself, so have no problem recommending it to others.

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Reflexive Control… sounds a bit scary.. what is it?

Iserson KV. Reflexive control in emergency medicine. Am J Emerg Med. 2024 Jul;81:75-81. doi: 10.1016/j.ajem.2024.04.037. Epub 2024 Apr 23. PMID: 38677197

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Sorry! WHAT DID YOU SAY?….

Adams C, Walsan R, McDonnell R, Schembri A. As loud as a construction site: Noise levels in the emergency department. Australas Emerg Care. 2024 Mar;27(1):26-29. doi: 10.1016/j.auec.2023.07.004. Epub 2023 Jul 31. PMID: 37532590

Bottom line: Emergency departments are noisy, although not ridiculously so.

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Can we all just agree that peripheral pressors are just fine?

Munroe ES, Heath ME, Eteer M, Gershengorn HB, Horowitz JK, Jones J, Kaatz S, Tamae Kakazu M, McLaughlin E, Flanders SA, Prescott HC. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. Chest. 2024 Apr;165(4):847-857. doi: 10.1016/j.chest.2023.10.027. Epub 2023 Oct 26. PMID: 37898185

Bottom line: If a patient needs a vasopressor, just start it through your peripheral IV, assuming you have one you trust. For the most part, central lines can be left to the ICU team during day time hours (and a good percentage of patients will never need one). 

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Don’t stress, just give the PPI and carry on.

Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024 Jul 4;391(1):9-20. doi: 10.1056/NEJMoa2404245. Epub 2024 Jun 14. PMID: 38875111 NCT03374800

Farkas has a deep dive on this topic in PulmCrit. 

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Maybe ED is not the best place for all patients!

Burton C, Mooney C, Sutton L, et al. Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England: the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial. Lancet. 2024 Jun 15;403(10444):2619-2629. doi: 10.1016/S0140-6736(24)00700-1. PMID: 38879261  

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Mythical Membrane Stabilisation meme

Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia Is Not Due to “Membrane Stabilization”. Crit Care Med. 2024 Jul 24. doi: 10.1097/CCM.0000000000006376. Epub ahead of print. PMID: 39046789

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