The Water Cooler

"The Water Cooler" is an online discussion forum where, every 6-8 weeks, residents, attendings, and MLPs discuss high-impact articles in the field of Emergency Medicine.  The discussion is meant to focus more on the clinical implications of the articles as opposed to the methodologic nuts and bolts.

After the discussion wraps up, we'll summarize the key points in a blog post bringing the discussion out from the private Google+ community and into the world of #FOAMed.  Feel free to peruse and lend your own voice to the discussion!

What are we Talking About This Month??

Up for discussion this month is a recent perspective article from Annals of Emergency Medicine - "The Opioid Prescription Epidemic and the Role of Emergency Medicine"

Much of the work we do focuses on relieving pain, but this has the consequence of increasing the supply of narcotic medications available to the public. With the number of deaths from prescription medication overdose increasing every year, how does our responsibility to the patient in front of us compare to our responsibility to the community at large?

What goes into your decision to prescribe narcotics? Do you find state guidelines or resources such as the OARRS database helpful? How do you communicate this with patients?

Recaps of Recent Water Cooler Discussions

Featured
The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap
The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

80% of heroin users start by abusing prescription medications – this is OUR problem         

Prescription medication overdose is now the leading cause of death from injury and the number of deaths from drug overdoses has increased every year since 1999. Estimates suggest between 6 and 12 million Americans receive prescription drugs either without prescription or without the intent of relieving pain. This article focuses on the ED provider’s role in this epidemic and offers strategies for improving training and education surrounding these medications. While heroin abuse tends to draw more attention, it is important to note that 80 percent of heroin users started their addiction by using prescription medications.

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Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown
Pre-Ox, Ap-Ox, and NO DESAT - Water Cooler Rundown

In 2012 in the Annals of Emergency Medicine, Weingart and Levitan published a review of preoxygenation and peri-intubation oxygenation techniques in the emergency airway management of adult patients.  Topics reviewed included the evidentiary support for preoxygenation and denitrogenation, appropriate positioning and patient selection, the utility of positive pressure in select circumstances, apneic oxygenation, as well as a proposed risk stratification approach based on pulse oximetry levels and peri-intubation risk.

A great discussion was had with many excellent learning points, upon which some were elaborated in great detail in the article and some only briefly mentioned.  What follows is a brief summary of learning points from the article as well as from the discussion. 

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Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH
Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH

Why Should You Care?

  • Headache approximates 2% of presenting complaints to the ED, and SAH is identified in approximately 1% of those patients with headache in the ED.
  • Overall mortality of SAH is high, estimated at 25-50% of patients dying within 6 months
  • If not fatal, SAH leaves approximately 33% of survivors with some appreciable neurological deficit affecting their ADLs.
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Water Cooler Breakdown: The ProCESS Trial
Water Cooler Breakdown: The ProCESS Trial

In March of 2014, Derek Angus and colleagues published the ProCESS trail in the NEJM (1)(N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602). In ProCESS, they explore the time-honored theory in EM-resuscitation that EGDT as described by Rivers (NEJM 2001) is the dominant strategy to improve survival in severe sepsis and septic shock. Despite the marked reduction in mortality that is reported in Rivers’ study, the study itself has not been successfully reproduced in a multicenter trial.

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