Sniffing out Sepsis - Vibes vs Scoring Systems?

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Sniffing out Sepsis - Vibes vs Scoring Systems?

Sepsis remains an increasingly common emergency department condition that is tied to higher morbidity and mortality across the United States as well  as the rest of the world. Sepsis as a disease process has been difficult to both clearly define and quickly recognize. Many metrics for recognition and management of sepsis are dependent upon various scoring systems, including SIRS, SOFA, qSOFA, and MEWS, none of which were designed for the acute detection of sepsis within the emergency department. This journal club recap will look at an article by Knack et al looking at physician gestalt vs scoring systems for the detection of sepsis.

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Grand Rounds Recap 8.2.23

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Grand Rounds Recap 8.2.23

We had a jam packed grand rounds this week, which was started off strong by Dr. Knight taking us through identifying sick vs. not sick patients. Drs. Della Porta and Kimmel then battled it out in this years first CPC. Next we were taken through acute ischemic stroke updates with the stroke team duo Drs. Demel and Kreitzer, followed by a quick hit lecture on AV blocks for the EM physician by Dr. Lang. We finished off the day with our R4 capstone reviewing over-testing in the ED with Dr. Yates followed by a review of what data to trust with Dr. Freiermuth and Sucharew for Research Grand Rounds.

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Grand Rounds Recap 7.6.2022

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Grand Rounds Recap 7.6.2022

This week we heard from Dr. Baxter about clinical reasoning and the pendulum of clinical thought one often goes through during residency. Dr. Thompson had a brief Operations update for trauma pages and sepsis. We were pushed to consider our own practice patterns with Dr. LaFollette’s cases of Hyponatremia, Sodium Nitrate and Syncope. The quick hits lecture series made its debut talking about QTc intervals, penetrating neck trauma, and a pneumonia research quick hit. We wrapped up the day with neuroimaging tips from Dr. Knight and understanding the care delivered to incarcerated persons at the Hamilton county justice center with Dr. Srivastava.

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The Thinker

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The Thinker

The reality of the Emergency Department is that not everybody is sick, but every patient could be sick. The task of finding the sick patients among the non-sick is far more challenging than it may appear and the diagnostic process is far more fraught with potential sources of error than one would like.

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Pneumonia Alphabet Soup

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Pneumonia Alphabet Soup

Pneumonia. It’s one of the first conditions we learn to diagnose as medical students. It was probably the cause of the first really sick, septic geriatric patient you saw in residency. Conversely you have also probably sent a fair share of patient’s home with an outpatient course of antibiotics and PCP follow-up.  While determining the appropriate treatment and disposition for patients on the extreme ends of illness severity is quite straight forward; that pesky majority in the middle can be a conundrum at times. Who can go home? Who needs broad spectrum? Who needs step-down? Over the last two decades there has been a smorgasbord of pneumonia related acronyms used in clinical practice to predict severity, guide therapeutics and recommend disposition. During our most recent resident Journal Club, we took a look at a handful of the more familiar acronyms as well as some new ones coming down the pipeline.

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A Healthy Dose of Fallibilism

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A Healthy Dose of Fallibilism
“Reason itself is fallible, and this fallibility must find a place in our logic.” - Nicola Abbagnano

Decision making in Emergency Medicine is intensely complex and it also the defining characteristic of the practice of Emergency Medicine.  To outside eyes we may seem to be a specialty of action: chest tubes, intubations, heroic resuscitations with massive amounts of blood products and IV infusions.  In truth none of the “action” of our specialty, the big sexy things they make into TV shows and movies, occurs without rapid, precise, and accurate thinking and decision making.  But the Emergency Department can be a hostile environment to the decision making process.   And, I’m not just talking about the noisy environment, the multiple interruptions, the patients with a wide variety of chief complaints and acuity seen in quick succession.  There’s seemingly a thousand different hurdles between the instant a patient recognizes that something might be wrong with them and the moment a clinician diagnoses the problem. 

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Clinical Approach to Knee Radiographs

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Early in the morning, you begin your day in your local emergency department. After getting yourself situated, a slow trickle of patients begin to appear on the board. It appears to be a normal morning, all except for the fact that five patients appear, one after the other, who have the same chief complaint: “Knee pain”. It is a good thing you brushed up on reading knee x-rays recently!

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The Cognitive Autopsy

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The Cognitive Autopsy

We are in a thinking profession.  

An outsider looking in on our profession may see procedures and action as the defining characteristics of the practice of Emergency Medicine.  But, reflecting on the attributes of the best EM docs I’ve worked with, their procedural excellence isn’t what stands out.  Thinking back on the great physicians I have met and worked with, the ones I strive to be like every day, it is their ability to think, lead, and educate that sticks with me the most.  

And, it turns out I’m not the only one who might see it like this…

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