VIP-EM POP QUIZ: What do you do?

During your emergency care career, you will not be able to avoid seeing the so-called VIP (very important…) patients from time to time. Whether it’s a VIP according to someone else higher up, general society or even your own perceptions actually does not matter – the end game is one and the same.

The best time to ponder and prepare regarding your future approach to VIP patients is now – before you are in the midst of the actual situation.

Now, if you are an idealist, things may seem blatantly easy. You shall and you of course will evaluate each one of your patients the same, regardless of anything about them! It may in fact feel insulting if someone were to insinuate that this case deserves or requires that “special” or “above and beyond” care. Doesn’t that imply that all of your other patients so far have been getting just average or so-so treatment?

A VIP patient is like a parcel box that arrives with a “handle with care” stamp. And the question is – are we not caring that way already?

Unfortunately, that is now how things may appear to others – exactly why patients and family members put on institutional badges or start mentioning names as you walk in the room. In a short while, random suits whom you have never met or knew existed descend from upstairs to “check on things”, as they seek you out to shake hands and make eye contact. And the general atmosphere affecting not only yourself, but also your nurses and everyone around slowly starts to resemble the buzz felt near a transformer booth.

The ethics and the philosophy of VIP-EM (I’m patenting the podcast name if you’re not) would take up a heavy volume.  For our purposes, we will make it simple:

VIP-EM situations will potentially push you toward one of two things:  either withholding what you normally would have done, or doing what you otherwise wouldn’t have done. 

Let’s take an example of either situation to illustrate.

  • A secretary of a hospital network CEO arrives with her 3-week old having a fever at home. Someone had called the charge nurse ahead of time, and they are given a priority room, ahead of others. The baby looks fine and is, oh, so cute! You, unfortunately, know what needs to happen, and so does the useless WBC count.  But…lumbar punctures hurt, and the mother is seeking out in your eyes the permission to defer it. So you send the happy baby home to its life-saving next day pediatrician follow up appointment and its Listeria meningitis demise…or do you?
  • A local TV station news anchor, and a friend of the Chief of the surgery department, pulls a shoulder while attempting a muscle up as part of the new IM-50X weight loss program. Physical exam findings are minimal, the XRay is normal and there is no concern for any neurological or vascular injury. You are requested to order a STAT MRI and to perform a shoulder steroid injection. Instead of the orthopedist on call, a special sports specialist catering to the town football team will be arriving in 3 hours to evaluate the patient, who will continue to hold up the ED bed. You will of course be prescribing narcotics for home…or will you?

Thinking about such hypothetical scenarios now to understand who you are and how you would behave will serve you well when the time comes. Regrettably, such education is often omitted from official medical school “handling difficult patients” curricula and cultural sensitivity training.

While I’m not an ethics professor, I do think there are three special circumstances within the entire VIP conundrum to consider.

The first is about returning someone injured in the line of public service to active duty. Whether it’s a colleague with a needle stick, a fireman needing clearance from minor inhalation or a police officer inadvertently embedded with a taser dart by one of his own – if you can return them to work rapidly and ahead of others, you should probably do it. First heal the healer goes a long way not only in major disasters, but in everyday life as well. It’s the basic utilitarian argument.

The second has to do with taking extra steps to ensure someone’s privacy.  If the patient is the kind of a persona who has paparazzi following them day and night, going the extra mile to create conditions of confidentiality that are no more than usual is probably okay.

Third, I do want to mention that while the sense of entitlement to extra or special care among the VIPs may be prevalent, the latter trend does not encompass everyone. Just like you will never plant the seed of suicidality by asking a patient if he or she is suicidal, you are unlikely to offend a potential VIP by asking directly if it is okay for you to treat them as everyone else. You will be amazed, but quite a few people who have to carry out their lives in full view of the public or are subjected to immense professional responsibilities never want to be treated differently in the first place.  Getting what I call a brief “fame holiday” may in fact be therapeutic and exactly what they need.

There are very few things in EM that are both deadlier and more unfair than VIP-medicine. Anticipating and mitigating potential fallout before it happens is a tough skill to learn. Knowing that such situations are unavoidable is the first step.

Last, while dignitary emergency medicine (DEM?) is not (yet) a legitimate EM fellowship, you can certainly read more about what’s being thought on this topic within the general medical field:

Al Mulhim MA, Darling RG, Kamal H, Voskanyan A, Ciottone G. Dignitary Medicine: A Novel Area of Medical Training. Cureus. 2019 Oct 22;11(10):e5962. doi: 10.7759/cureus.5962. PMID: 31799098; PMCID: PMC6863586.

 

Cite this article as: Anthony Rodigin, USA, “VIP-EM POP QUIZ: What do you do?,” in International Emergency Medicine Education Project, May 10, 2021, https://iem-student.org/2021/05/10/vip-emergency-medicine/, date accessed: December 5, 2022

Recent Blog Posts By Anthony Rodigin

Special Populations in the ED: Drug Users

Drug users have a different reputation among health care providers, especially in the ED. According to World Health Organization (WHO), in 2018, an estimated 269 million people, or 5.4 percent of the global population aged 15–64, had used drugs in the previous year (1). Here we will focus on opioid users, which accounts for 57.8 million people globally in 2018, specifically the acute pain management in these patients.

What do I have to know about them:

Patients with opioid dependency can have three major obstacles to pain management

  1. Opioid-Induced Hyperalgesia (OIH): A sensitive disorder is caused by chronic use of opioids; It can affect patients under opioid use for chronic pain control, patients under substitution therapy (methadone and buprenorphine), and those abusing heroin. OIH typically produces diffuse and not well-defined pain.
  2. Opioid tolerance: These patients report higher pain scores, have slower pain resolution, and experience a longer hospital stay with an increased chance of readmission, compared with opioid-naive patients. Tolerance to CNS, respiratory, and analgesic effects develops quickly, while tolerance to constipating effects may not happen. (3). Cross-tolerance is a tolerance that patients taking chronic methadone need higher doses of morphine for pain relief than occasional IV heroin users (3), suggesting a cross-tolerance between methadone and other opioids.
  3. Opioid withdrawal: Symptoms are caused by sympathetic activation: tachycardia, sweating, insomnia, diarrhea, and anxiety. Opioid substitution therapy (OST), usually with methadone, is crucial in treating those in rehab from opioid abuse.
drug users 2

How could this be a problem?

  • Overtreatment: Higher dose equals more toxicity. Because of the OIH and opioid tolerance, higher doses may be necessary to relieve pain in these patients. Clinicians are generally afraid to give a higher amount of opioids due to the risk of toxicity, especially respiratory depression.
  • Relapse x undertreatment: Another common fear among clinicians is inducing a relapse in an abstinent patient or OST, leading to undertreatment of pain. This, instead of opioid use, has more power to cause a relapse. (2)

Acute pain management in the chronic opioid user

  • OIH (2): Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatories, and local anesthetics as “opioid-sparing drugs.” Adjuvant therapies also play an essential role, with ketamine, gabapentin, and pregabalin showing promising results in reducing OIH.
  • Withdrawal (2): Methadone in small doses (10 – 20 mg) can be used to prevent withdrawal symptoms in patients who are not in OST. Methadone can cause QT-interval prolongation
  • Toxicity (4): As commented above, chronic opioid users develop tolerance to respiratory and CNS effects as well, giving more space to higher doses of opioids for pain management. If toxic effects happen, provide ventilatory support and use antidotes (naloxone) if needed. Classic signs of opioid toxicity are as follows; decreased respiratory frequency (best predictor if < 12), depressed mental status, miotic pupils (however, normal pupils does not exclude opioid toxicity). 
  • Tolerance (3): Around the clock dosing is recommended rather than “as needed.” For patients on OST, their regular dose of methadone/buprenorphine should be continued alongside additional doses of short-acting opioids and other analgesics for adequate pain control.

Disposition to home (3)

The most crucial action here is to contact the assistant physician who is prescribing the opioids and make he/she knows what happened, how it was managed, what medications were prescribed, and in which dose. If opioids are needed for pain control at home, consider the services available in the outpatient setting: 

  • Immediate-release preparations are more effective for acute pain relief but carry a higher risk of abuse. If it is possible to arrange more frequent appointments, small doses of the medication can be prescribed, and the patient can be closely monitored.
  • If a closer follow-up is not possible, long-acting formulations are the safest way to provide good analgesia with a smaller risk of abuse.
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Drug Users," in International Emergency Medicine Education Project, March 10, 2021, https://iem-student.org/2021/03/10/drug-users/, date accessed: December 5, 2022

Recent Blog Posts by Arthur Martins

References and Further Reading

  1. United Nations World Drug Report 2020 (available at https://wdr.unodc.org/wdr2019/
  2. Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2(4):e611. Published 2017 Jul 27. doi:10.1097/PR9.0000000000000611
  3. Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep. 2016;20(5):35. doi:10.1007/s11916-016-0561-0
  4. UpToDate: https://www.uptodate.com/contents/acute-opioid-intoxication-in-adults?search=opioid&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4
  • UN World Drug Report 2020 – https://wdr.unodc.org/wdr2020/index.html
  • Haber PS, Demirkol A, Lange K, Murnion B. Management of injecting drug users admitted to hospital. Lancet. 2009;374(9697):1284-1293. doi:10.1016/S0140-6736(09)61036-9
  • Sahota PK, Shastry S, Mukamel DB, et al. Screening emergency department patients for opioid drug use: A qualitative systematic review. Addict Behav. 2018;85:139-146. doi:10.1016/j.addbeh.2018.05.022



Special Populations in the ED: Athletes

special populations in the ED athletes

It is common to hear that “when you work in an Emergency Department (ED), you have to be prepared for everything”. In my experience as a medical student, this could not be more true. I’ve seen tea overdose, collision scooter vs horse, and anything in between. All these experiences will contribute to my formation and made me realize that we are not prepared for many situations. Some of these situations may involve specific populations we’re not so familiarized with and sometimes can change the way we manage an emergency.

Here, I want to discuss some of these “special populations” which may demand a different approach than the usual – and that is what makes emergency medicine so interesting. Let’s talk about one of these subgroups of patients: athletes, and what makes them unique.

Athletes: What do I need to know about them?

  • Heart and Hemodynamic: The “athlete’s heart syndrome (1)”
    • Morphological, functional and electrical changes
      • Lower heart rate;
      • Hypertrophic left ventricle (LV)
      • Lifelong cardiac remodelling could lead to arrhythmogenic pathways
  • Changes in autonomic nervous system – vagal tonus
  • Pulmonary efficiency:
    • Unlike what may be the first thought, the respiratory system does not differ greatly in athletes from non-athletes (2).
  • High energy trauma:
    • Be aware that professional athletes are constantly at risk of high energy traumas, in special head traumas (concussions) and limb trauma (fractures);

How could this be a problem?

  • Late signs of hypovolemia
    • The athlete’s autonomic nervous system has pronounced vagal tonus, which leads to the famous resting bradycardia – this could disguise a tachycardia, one of the early signs of hypovolemia (2).
  • Delay in seeking help
    • Elite athletes may delay seeking help or admit they are not feeling well for fear of losing a competition or training sessions.
    • Besides that, in amateur (and sometimes even in professional) level competitions, staff and coaches often are not trained to identify conditions that need prompt medical assistance

Common situations and how to manage

Exercise and health always have been put together in a “cause and consequence” relation. Besides their undeniable positive effects, exercise on the professional level also has its sidebacks and associated risks. Here I want to discuss some physiological changes we observe in the elite athletes and a very common condition in the ED: the sport-related concussion.

Sport-related concussion (3,4) is a traumatic brain injury induced by biomechanical forces. It may be caused either by a direct impact to the head or by a force transmitted from the impact elsewhere in the body; It typically presents with rapid onset of short-lived signs and symptoms; However, the course is sometimes unpredictable and may evolve in minutes to hours; It may or may not have a decreased level of counsciousnes.

The current literature organize the signs and symptoms of sport-related concussion in 4 domains

  1. Somatic
    • Headache, dizziness, gait disturbances, vertigo, nausea and vomiting, near vision impairment
  2. Cognitive
    • Impaired memory (amnesia), slowed speech, confusion,
  3. Sleep
    • Insomnia
  4. Emotional
    • Irritability, labile humour

Given the rapid onset and short duration, the patient might present to the ED with minor or no symptoms; However, the emergency physician still plays an important role, providing supportive care to relieve remaining symptoms and rule out more severe conditions.

Attention

  • Due to the mechanism of trauma, always rule out cervical spine lesions or instability.
  • Also, signs of basilar skull fracture (racoon eyes, Battle’s sign, CSF rhinorrhea)
  • A Glasgow Coma Scale < 13 should raise awareness for a more severe brain lesion.
  • Does this patient need a head CT?
    • Canadian CT head rule (adults)
    • PECARN CT rule (under 16)   

Management (4)

Headache: 86% had significant pain reduction, and 52% had complete headache resolution after receiving an intravenous dose of one or more of the following: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Common orally administered analgesics such acetaminophen, non-steroidal anti-inflammatories and triptans have shown efficacy for pain relief, but there are no studies in the ED setting.
 
Dizziness: Suspicion for peripheral vertigo can be confirmed by the Dix-Hallpike manoeuvre and treated with the Epley manoeuvre. Meclizine (vestibular suppressant) and diazepam can be used with caution because of potential side effects on cognition and alertness.
 
To date, rest continues to be recommended for the acute (24-48h) injury period. After that period, patients can be encouraged to become gradually more active, always below their cognitive and physical limits.

When to admit

This decision is based on the patient’s clinical status. Persistent symptoms and alterations on head CT are the most common indications for admission. 
 
Discharging to home: Education is key for recovery and prevention of recurrence (4). Current evidence indicates that written educational material is more effective than orally given instructions only; Important information that should be present in the educational material are expected symptoms, their management and a timeframe of resolution. 
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Athletes," in International Emergency Medicine Education Project, March 8, 2021, https://iem-student.org/2021/03/08/special-populations-in-the-ed-athletes/, date accessed: December 5, 2022

Recent Blog Posts by Arthur Martins

References and Further Reading

  1. Carbone A, D’Andrea A, Riegler L, Scarafile R, Pezzullo E, Martone F, America R, Liccardo B, Galderisi M, Bossone E, Calabrò R. Cardiac damage in athlete’s heart: When the “supernormal” heart fails! World J Cardiol 2017; 9(6): 470-480 Available from: URL: http://www.wjgnet.com/1949-8462/full/v9/i6/470.htm DOI: http://
    dx.doi.org/10.4330/wjc.v9.i6.470
  2. ACSM’s advanced exercise physiology. — 2nd ed.;Peter A. Farrell, Michael Joyner, Vincent Caiozzo ISBN 978-0-7817-9780-1
  3. McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847
  4. Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med. 2020;75(4):471-482. doi:10.1016/j.annemergmed.2019.05.032