In this episode I talked with Dr. Quinn Cummings (@resus_bae) about the topic of cognitive bias and some ways we can reduce the influence of biases in our practice. Quinn is an emergency physician with a special interest in this topic.

During an average shift an emergency medical provider makes hundreds to thousands of decisions. To make these decisions, our brains use a combination of conscious and subconscious information. We tend to think that all our decisions are made objectively but, in fact, much of our decision making comes from knowledge or ideas that we are not even aware of. This is the concept of cognitive bias. A cognitive bias is a systematic error in thinking which can skew our ability to process information properly and accurately. This can lead to an improper diagnosis or treatment path for our patient. There are numerous examples of specific biases such as anchoring bias, confirmation bias, premature closure, etc. We discuss a few examples in the podcast but we encourage you to research more to see which ones you may be more susceptible to (see resources below).

As always please feel free to share feedback, comments, or questions!

Twitter: @amerelman

Instagram: @paramedicpractitioner  

Facebook: The Paramedic Practitioner Podcast

Email: amerelman@gmail.com

References and other resources:

https://www.nuemblog.com/blog/cognitive-bias

https://first10em.com/cognitive-errors/

https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/


Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Med. August 2003, 1-6.

Croskerry, P et al. Patient Safety in Emergency Medicine. Lippincott Williams & Wilkins, 2009.

Thomas, D. D., & Mustafa, Y. Design for cognitive bias. Jeffrey Zeldman / A Book Apart. 2020.

Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med 2003;41(1):110–120.

Croskerry P. The feedback sanction. Acad Emerg Med. 2000 Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471.

Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960.

Abraham Kaplan (1964). The Conduct of Inquiry: Methodology for Behavioral Science. San Francisco: Chandler Publishing Co. p. 28. ISBN 9781412836296.

Allison, Scott T; Messick, David M (1985). “The group attribution error”. Journal of Experimental Social Psychology. 21 (6): 563–579. doi:10.1016/0022-1031(85)90025-3

Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Quality & Safety 2016;25:808-820.

Benau EM, Orloff NC, Janke EA, Serpell L, Timko CA. A systematic review of the effects of experimental fasting on cognition. Appetite. 2014 Jun;77:52-61. doi: 10.1016/j.appet.2014.02.014. Epub 2014 Feb 27. PMID: 24583414.

Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: A meta-analytic review. Neurosci Biobehav Rev. 2017 Sep;80:586-604. doi: 10.1016/j.neubiorev.2017.07.010. Epub 2017 Jul 28. PMID: 28757454.

O’Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see.

Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM.

A Law Enforcement Approach to ExDS

References and Resources

https://www.nuemblog.com/blog/chemical-sedation

https://www.acepnow.com/article/droperidol-is-back-and-heres-what-you-need-to-know/

http://www.tamingthesru.com/blog/2019/4/20/the-return-of-droperidol

https://havokjournal.com/fitness/medical/ketamine-it-may-not-be-a-solution-for-everything-but-its-not-at-fault-here/

Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): Redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006


Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000-1004. doi:10.1016/j.ajem.2017.02.026


Parsch CS, Boonstra A, Teubner D, Emmerton W, McKenny B, Ellis DY. Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study. EMA – Emerg Med Australas. 2017;29(3):291-296. doi:10.1111/1742-6723.12763

Miner JR. Ketamine is a good first-line option for severely agitated patients in the prehospital environment. Am J Emerg Med. 2018;36(3):501-502. doi:10.1016/j.ajem.2017.12.015

Michaud A. Restraint related deaths and excited delirium syndrome in Ontario (2004-2011). J Forensic Leg Med. 2016;41:30-35. doi:10.1016/j.jflm.2016.04.010

Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018;38(1):139-151. doi:10.1002/phar.2060

Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1. doi:10.1016/j.annemergmed.2015.11.028

Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. J Emerg Med. 2015;48(6):712-719. doi:10.1016/j.jemermed.2015.02.019

Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330

Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12(12):CD002830. Published 2016 Dec 15. doi:10.1002/14651858.CD002830.pub3

Lai PC, Huang YT. Evidence-based review and appraisal of the use of droperidol in the emergency department. Ci Ji Yi Xue Za Zhi. 2018;30(1):1-4. doi:10.4103/tcmj.tcmj_195_17

Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385. doi:10.1016/j.annemergmed.2018.04.027

Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749. doi:10.1197/j.aem.2003.06.015

Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8(Suppl 8):45-47. doi:10.1111/j.1528-1167.2011.03235.x

Ramsay RE, Wilder BJ, Uthman BM, et al. Intramuscular fosphenytoin (Cerebyx®) in patients requiring a loading dose of phenytoin. Epilepsy Res. 1997;28(3):181-187. doi:10.1016/S0920-1211(97)00054-5

Hopkins U, Arias C. Large-volume IM injections: a review of best practices. Oncol Nurse Advis. 2013;4(february):32-37.

Harrington L. Administer single-site 30-mL intramuscular injection? Medsurg Nurs. 2005;14(6):379-382.

Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl alcohol swabbing before injection really necessary? Med J Aust. 2001;174(6):306. doi:10.5694/j.1326-5377.2001.tb143279.x

Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger G. The safety of injecting insulin through clothing. Diabetes Care. 1997;20(3):244-247. doi:10.2337/diacare.20.3.244

Khawaja RA, Sikanda R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. J Liaquat Univ Med Heal Sci. 2013;12(2):109-114.

Sponsored by Prodigy EMS

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.

Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman


Image: PulmCrit

References and Further Reading
UpToDatehttps://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://err.ersjournals.com/content/22/129/227.full
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pubmed/11406055
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740
https://www.ncbi.nlm.nih.gov/pubmed/26033128
https://www.ncbi.nlm.nih.gov/pubmed/25447559
https://www.ncbi.nlm.nih.gov/pubmed/27289336
https://www.ncbi.nlm.nih.gov/pubmed/18922662
https://www.ncbi.nlm.nih.gov/pubmed/28754601
https://www.ncbi.nlm.nih.gov/pubmed/24865567
https://www.ncbi.nlm.nih.gov/pubmed/24731521
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.


Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.


Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman

Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.

Image: PulmCrit

References:

References
UpToDate
https://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740

http://www.cmaj.ca/content/188/17-18/E466
Mechanism of Slow-Fast AVNRT
http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
AVNRT versus AVRT
http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRT
http:// https://litfl.com/sinus-tachycardia-ecg-library/
Atrial fibrillation with rapid ventricular response. Not the lack of visible P waves and irregularity that make the diagnosis.
http:// https://litfl.com/atrial-fibrillation-ecg-library/
Atrial flutter with 2:1 conduction. Rate of 150 and fairly obvious flutter waves are present.
Atrial flutter with 2:1 conduction. Flutter waves are not overtly obvious, but the rate of 150 bpm helps suggest atrial flutter. Treatment with diltiazem will slow conduction and help reveal the flutter waves and treat the rate.
Atrial flutter with 1:1 conduction. The rate of 300 and regularity of QRS complexes helps confirm the diagnosis.
http:// https://litfl.com/atrial-flutter-ecg-library/
AVNRT. A regular, narrow-complex tachycardia without obvious P-waves.
http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
AVRT in a patient with WPW. A regular, narrow-complex tachycardia without obvious P-waves.
http:// https://litfl.com/pre-excitation-syndromes-ecg-library/
Junctional tachycardia. Retrograde P-waves are obvious before the QRS complexes but they are not always visible.
http:// https://litfl.com/accelerated-junctional-rhythm-ajr/
Atrial fibrillation with WPW. Note the extremely rapid rate, 300 bpm at times, the wide QRS complexes and varying QRS morphologies. These features confirm the diagnosis.
Another example of atrial fibrillation with WPW. This is difficult to distinguish from polymorphic ventricular tachycardia.
http:// https://litfl.com/pre-excitation-syndromes-ecg-library/
1. Patient sitting upright on stretcher
2. Patient blows into syringe for 15 seconds
3. At 15 seconds quickly lay patient supine and elevate the legs
http:// https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/

Reference:

    Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. Cochrane Database Syst Rev. 2017 Oct 12;10:CD005154. doi: 10.1002/14651858.CD005154.pub4.
    Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4.
    Bibas L, Levi M, Essebag V. Diagnosis and management of supraventricular tachycardias. CMAJ. 2016;188(17-18):E466–E473. doi:10.1503/cmaj.160079
    Hafeez Y, Armstrong TJ. Atrioventricular Nodal Reentry Tachycardia (AVNRT) [Updated 2019 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499936/

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.

Airway Checklist Examples

Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.com
Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.

Reference:

This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful.

Ear-to-sternal-notch positioning
Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE)
The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency.

Reference:

In this episode I discuss prehospital management of traumatic cardiac arrest, broken into penetrating and blunt. In recent years the pendulum has swung away from a nihilistic approach towards one that maximizes outcomes in the highest number of patients. This requires taking a standardized, aggressive approach when treating viable patients with traumatic arrest. In penetrating traumatic arrest, addressing reversible causes based on the location of the injury is essential. This primarily means hemorrhage control and volume restoration (ideally with blood products). It may also mean chest decompression (ideally with finger thoracostomy) for treatment of pneumothorax or hemothorax.

In blunt arrest it is more difficult to determine an underlying cause of arrest so a rehearsed, pre-planned “bundle” of care directed at reversible causes should be delivered early. Chest compressions should not be expected to be effective until volume is restored or tension physiology is reversed. This approach is attributed by most people to Dr. John Hinds.

Primary interventions include:

  1. Aggressive control of external hemorrhage.
  2. Maintenance of airway and ensuring oxygenation, ideally with intubation
  3. Decompression of both sides of the chest, ideally with finger thoracostomy but needle thoracostomy at minimum
  4. Application of a pelvic binder
  5. Reduction of all long bone fractures

References

    Scott Weingart. EMCrit Podcast 135 – Trauma Thoughts with John Hinds. EMCrit Blog. Published on October 19, 2014. Accessed on May 24th 2019. Available at [https://emcrit.org/emcrit/trauma-thoughts-john-hinds/ ].
    Traumatic cardiac arrest: a unique approach. Harris T, Masud S, Lamond A, Abu-Habsa M. Eur J Emerg Med. 2015 Apr;22(2):72-8. doi: 10.1097/MEJ.0000000000000180. Review.
    Konesky KL, Guo WA. Eur J Trauma Emerg Surg. 2018 Dec;44(6):903-908. doi: 10.1007/s00068-017-0875-6. Epub 2017 Nov 25.
    Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC. Resuscitation. 2018 Oct;131:48-54. doi: 10.1016/j.resuscitation.2018.07.032. Epub 2018 Jul 27.
    Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285–293. doi:10.1097/TA.0000000000001070

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias.

References:

    http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia
    https://emcrit.org/ibcc/hyperkalemia/
    Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033
    Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3
    Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15

(ECGs from Smith’s ECG Blog http://hqmeded-ecg.blogspot.com)

Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5
Hyperkalemia indicated primarily by peaked T-waves in V2-V4
Wide QRS and significantly peaked T-waves indicating hyperkalemia
Substantially widened QRS with sine wave morphology indicating severe hyperkalemia

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter.

References

    Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710
    Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004
    Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23
    Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.
    Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/
    IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM
    IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net