Portal de Periódicos da CAPES

Learn Something New, Connect with Colleagues

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 10 Linguagem: Inglês

10.1097/01.eem.0000990108.12403.6c

1552-3624

Gina Shaw,

Trauma and Emergency Care Studies

Figure: ACEP, conference, scientific assembly, IPV, pain management, sexual assault, Danger Assessment Instrument, pregnancy, opioids, NSAIDs, COX-2 inhibitors, ketorolac, lidocaine, dopamine, acetaminophen, opioids, opioid use disorder, transgender, patients, nonbinary, ketamineEPs attending this year's American College of Emergency Physicians Scientific Assembly in Philadelphia in October will find a wealth of practical information in lectures from top experts in the field. Here is a preview of just a few of the lectures planned. But Did You Ask? IPV and Sexual Assault Tuesday, Oct. 10, 1 p.m. Almost half of all patients who are killed by an abusive intimate partner were evaluated in the emergency department within the 24 months preceding the homicide. (Am J Emerg Med. 1999;17[7]:689.) “My overarching goal in our session on intimate partner violence and sexual assault is to raise awareness of this public health emergency, and leave emergency clinicians with an understanding of how we can really make a difference in those brief moments we have in the ED, if we have an understanding of how to start the conversation and questions we can ask,” said Joelle Borhart, MD, an associate professor of emergency medicine at Georgetown University Hospital and Washington Hospital Center in Washington, D.C. Dr. Borhart will review the Danger Assessment Instrument, a method for assessing the potential lethality of a patient's situation. (https://bit.ly/3KWfMcL.) Developed originally by Johns Hopkins University School of Nursing Associate Dean Jacquelyn Campbell, PhD, it has recently gained traction with police and first responders who often respond to IPV cases, Dr. Borhart said. “The entire assessment can be lengthy, but there are some key questions and topics that we are going to pick out for the audience to focus their conversations when talking to patients that are particularly helpful with assessing how high risk the situation is,” she explained. “Some of these include access to a gun, history of strangulation, threats of harming or killing the partner, and characteristics such as children in the home who are not the abuser's, and unemployment or recent job change for the abuser.” Pregnancy is a high-risk circumstance that should also raise red flags about IPV risk in the context of other risk factors. “Violence can begin for the first time during pregnancy, or it can escalate rapidly,” Dr. Borhart said. The session will also include tips for how to frame an uncomfortable or difficult conversation that the audience will likely find applicable to many clinical situations, not just IPV. “This is all powerful information to know,” said Dr. Borhart. Opiates Are Out. What Pain Management Is In? Tuesday, Oct. 10, 8 a.m. Gone are the days of a single pain management solution for most patients in the emergency department, said Alexis LaPietra, DO, the system director for Addiction Medicine, Emergency and Hospitalist Services at RWJBarnabas Health and a founder of the Pain Management and Addiction Medicine Section of ACEP. Her session will explore the most up-to-date findings on what does and does not work for pain relief. “I don't think this will be new to a lot of us. We are looking for a multimodal approach,” she said. “We are typically layering a few different non-opioid medications, combining orals with topicals like creams and patches, to seek a synergistic effect. In some patients, particularly the elderly or those with renal or gastrointestinal issues who may have contraindications to medications such as NSAIDs, is there evidence that we might be able to just use topicals?” Dr. LaPietra said she also planned to discuss the evidence for and against less commonly used NSAIDs, including more selective COX-2 inhibitors such as celecoxib and rofecoxib and less selective agents such as ketorolac. “A few years ago, there was excitement about IV lidocaine as an alternative pain management option in renal colic, but we have since come to understand that it's probably not that silver bullet and are shying away from it as a gold standard,” she added. “In different populations where we have to think creatively, however, it is still probably an option.” She said she will also explore dosing and delivery strategies for IV ketamine, the availability of dopamine receptor agonists such as droperidol, new data on the indications for IV acetaminophen, and the risks of misuse of gabapentin and pregabalin, which have become commonly used for neuropathic pain. “At the end, I will still talk about opioids,” she said. “Although we are focusing on alternatives and that is where we need to practice evidence-based care, opioids are still out there, and we do still need to use them. We can't hold back on providing comprehensive pain care just because we have become afraid to give opioids.”Figure: No visit to Philadelphia is complete without eating at least one cheesesteak, and two of the most famous spots are near each other in South Philly.She noted that certain opioids pose more risk than others. “Oxycodone appears to have unique pharmacologic properties that make it really ‘likeable’ for the brain. A lot of opioid use disorder started, as we know, from really potent prescriptions that were not being written from the ED. Now we know more about that oxycodone molecule and what it's doing to spike dopamine and hit the addiction centers of the brain, setting people down this problematic pathway,” she said. She added that other oral full agonists like morphine work just as well for pain but don't cause the same massive euphoria.Figure: Fans of the TV show “It's Always Sunny in Philadelphia” will recognize the 19th century boathouses lining the Schuylkill River.Emergency Care for Transgender Patients Tuesday, Oct. 10; 1 p.m. The emergency department can be a particularly stressful environment for people who are transgender or nonbinary. One study found that nearly half of transgender and nonbinary individuals surveyed avoided needed ED care due to anticipated discrimination, long wait times, and previous negative experiences. (Ann Emerg Med. 2018;71[2]:170; https://bit.ly/3s7rYAN.) Patients have reported being misgendered, asked inappropriate questions, treated like a zoo exhibit, and experiencing care delays. (J Emerg Med. 2021;61[4]:396; https://bit.ly/3KC3Axk.) “There is a substantial body of research indicating that emergency department care of transgender patients is often inappropriate,” said Lauren Westafer, DO, an assistant professor of emergency medicine at UMass Chan Medical School-Baystate. “Often, when we think about emergency care of patients who are transgender, we immediately focus on medical complications of procedures or medications, and we forget the basic foundation of care that comes before that, which includes treating the patient with dignity through such behaviors as respecting their name and pronouns.”FigureDr. Westafer said she will focus on practical tips to establishing the trust that is key to the appropriate care of transgender patients. “A lot of physicians still stigmatize these patients,” she said, citing a study her group published finding that transgender and gender expansive (TGE) physicians report biased treatment by their colleagues. (JAMA Network Open. 2022;5[6]:e2219791; https://bit.ly/3KEW4BV.) “People who don't know that they are trans show their biases and what they think of them as people,” she said. “Many participants reported witnessing colleagues be respectful in front of a trans or gender expansive patient, yet in nonpatient-facing arenas engage in misgendering and/or overt bias, typically when they did not know their colleague was TGE.” Dr. Westafer will discuss nonstigmatizing ways to ask a patient's gender, name, and pronouns and focus on using the correct terms. “You need to show that you can be a safe space, so that people are more likely to give you the full history that they may otherwise be scared to divulge,” she said. “That can be as simple as wearing a pronoun pin. You can also work to make sure that your ED and your hospital has updated their EHR and has protocols in place to document gender in appropriate ways. It can be hard as an individual to create system-level change, so if you can't do that, and you know that a patient's chart name isn't the right one, do what you can to make sure your care team knows the right name and pronouns to use so that the person isn't asked multiple times about their gender identity and referred to by their deadname.” Dr. Westafer stressed that emergency physicians take care of patients who are transgender and nonbinary without even knowing it. “It's called being stealth. People can choose to mask in a setting in which they don't feel safe,” she said. “Statistically, you have probably interacted with someone thinking that they were cisgender when they were in fact trans. So how you talk matters, all the time.” Keeping Kids Calm Without Ketamine Tuesday, Oct. 10, 3:30 p.m. As a program director for emergency medicine residents at Carolinas Medical Center in Charlotte, NC, Sean Fox, MD, a professor of emergency medicine and pediatrics, tries to ensure that his trainees are comfortable caring for children. “I spend half my clinical time taking care of children in the pediatric ED and the other in the adult ED,” he said. “The maxim that ‘children aren't little adults’ gets said time and time again, and while it has its purpose, it can also engender fear in the clinician, possible causing them to be anxious. I want everyone to feel empowered taking care of kids. When you're comfortable taking care of kids, they are comfortable with you taking care of them.”Figure: Be in the room where it happened at Independence Hall, the place where Declaration of Independence and the United States Constitution were debated and adopted.Dr. Fox said he will discuss in his Scientific Assembly session how to engender trust with children in anxiety-producing situations. “Many of my colleagues and residents will tell me that part of the issue they have with taking care of kids is that something simple, like looking in their ear, can lead to such levels of anxiety in the patient that the anxiety is replicated in the provider,” he said, “and that can make something that should be relatively easy become very difficult.” Many emergency physicians are comfortable giving ketamine to help keep a child calm when they have a significant injury such as a broken bone or major laceration,” he said. “But we shouldn't have to use sedatives to do simple things like look in a child's ear. We also need to dispel the myth that you just need to blow bubbles and a child will be happy. We can treat children like humans that are able to be responsive to conversations and information because they are.” Dr. Fox's talk will include simple strategies to keep children interested and engaged and distract them without being dishonest. “If you deceive a child, once they find out you're lying they will no longer trust you again,” he said. “For example, never offer options that don't exist. That's something I've learned both in practice and as a parent. In the pediatric ED, a common failing is asking a patient, ‘Are you ready for your sutures?’ Then the child says, ‘No.’ What do you do now? You offered an option, and they took the one you weren't expecting. You meant your statement as, ‘It's time to do your sutures now,’ but that's not how they took it. You've just undermined the trust you have with that child, and they're no longer a fan of yours.” Instead, Dr. Fox said, offer only options that actually exist in the situation. “You can say, ‘Okay, we're going to do your sutures now. Do you want to count them, or do you want to sing a song?’ It doesn't matter to you which of those options the child chooses in that case, and you're not offering them a choice that you'll then take away.” And don't discount a child's feelings. “When a child is crying and you're trying to placate them and alleviate their stress, it can be tempting to say something like, ‘There's no need to cry; you're doing fine,’” he said. “That's not your decision to make. The child does have a reason to cry, and you need to respect those feelings. Instead, you can say something like, ‘I know it's scary. I'm here for you.’” MS. SHAW is a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work at www.writergina.com. Follow her on Twitter @writergina.