Safety and Efficacy of Low-Dose Versus High-Dose Parenteral Ketorolac for Acute Pain Relief in Patients 65 Years and Older in the Emergency Department.

Background There is limited data surrounding acute pain management in elderly ED patients. Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with dose/duration-dependent side effects. There is evidence that an analgesic ceiling effect exists for parenteral ketorolac doses greater than 10 milligrams (mg); however, this has not been studied in patients 65 years and older. Methods This was a retrospective chart review of ED patients 65 years and older who received at least one dose of parenteral ketorolac. Patients were separated into two cohorts based on the ketorolac dose received: 15 mg IV or 30 mg intramuscular (IM) and 30 mg IV or 60 mg IM. The primary objective was to evaluate the analgesic efficacy of parenteral ketorolac doses measured as needing rescue analgesia from 30 minutes to 2 hours after ketorolac administration. Secondary objectives included changes in pain scores and the occurrence of adverse drug events commonly associated with ketorolac. Results Two-hundred and sixty patients received ketorolac doses of 15 mg IV or 30 mg IM, and 52 received 30 mg IV or 60 mg IM. The primary outcome occurred in seven of 52 patients who received ketorolac 30 mg IV or 60 mg IM and 17 of 260 patients who received ketorolac 15 mg IV or 30 mg IM (13.5% vs. 6.5%, p=0094; OR: 2.22, 95% CI: 0.87-5.67). The average change in pain scores were 2.9 (±3.1) and 2.8 (±2.9) for patients who received doses 30 mg IV or 60 mg IM compared to doses 15 mg IV or 30 mg IM, respectively (p=0.154). The occurrence of adverse events was low in both groups. Conclusion Parenteral ketorolac doses of 15 mg IV or 30 mg IM did not demonstrate a greater need for rescue analgesia compared to doses of 30 mg IV or 60 mg IM.

What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario.

Audience: The primary audience for this simulation exercise is emergency medicine (EM) residents, although it could be more broadly applied to all provider groups, including medical students, advanced practice providers, and faculty physicians. Introduction: Over the course of their professional careers, approximately 10-15% of physicians will misuse or abuse alcohol or drugs.1 Unfortunately, Emergency Physicians (EPs) are not immune to this phenomenon, and although EPs make up only 4.7% of the active physician workforce,2 they are over-represented in samples of physicians referred to physician health programs (PHPs) for substance use disorder.3 Despite this increased prevalence, when EPs were referred to a PHP by themselves, family, or colleagues, 84% of them completed the program and were practicing medicine 5 years later,3 which makes recognition and referral of the impaired physician an important step to provide the treatment needed for recovery and ultimately for return to practice. Given the prevalence of substance use disorder in EPs, it is not surprising that the 2019 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements in Emergency Medicine stipulate that "residents and faculty members must demonstrate an understanding of their personal role in the recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team."4 Furthermore, the common program requirements also outline that each residency program must have "designated individuals responsible for reporting impaired providers in accordance with each institution's policies as well as being knowledgeable in the resources available to said provider."4 Despite these requirements, there are no best practices available to outline how residency programs can effectively teach trainees how to recognize and report the impairment. This simulation scenario is intended to provide an opportunity for learners to recognize an impaired colleague in a clinical setting, remove them from the clinical care environment, and notify the appropriate contacts, such as a Program Director, Department Chair, or nursing supervisor. To our knowledge, this is the first described simulation scenario where learners develop competency in recognizing and reporting the impaired provider. Objectives: By the end of this simulation, learners will be able to: 1) Identify potential impairment in the form of alcohol intoxication in a physician colleague; 2) demonstrate the ability to communicate effectively with the colleague and remove them from the patient care environment; 3) discuss the appropriate next steps in identifying long-term wellness resources for the impaired colleague; and 4) demonstrate understanding of the need to continue to provide care for the patients by moving the case forward. Educational Methods: This scenario is a simulated encounter taking place in the emergency department (ED) where the patient is a trauma activation who is not critically ill; the learner's confederate colleague in the scenario arrives for sign-out smelling of alcohol and appearing intoxicated. The learner will need to both provide care for the injured patient while addressing their colleague's impairment and safely removing them from the patient care area. Research Methods: The effectiveness of this simulated scenario as a teaching instrument was evaluated utilizing an internally developed evaluation survey that is part of the standard simulation curriculum at West Virginia University (WVU). The survey consisted of questions both regarding the effectiveness of the instructors as well as of the simulation, rated on a Likert scale. Learners were given the opportunity to answer free response questions where they were asked to reflect upon their experience, including the strengths of the experience and any identified opportunities for improvement. Results: Using a standard Likert scale, learners completing the impaired provider simulation scenario reviewed the effectiveness of the simulation and instructors very positively, with the vast majority of learners scoring all aspects of the scenario either as a 4 or 5. The free response answers were universally positive with many participants considering the experience very useful for training on a topic that is not frequently taught in other portions of the formal didactic curriculum. Discussion: While it is fortunately rare to encounter a colleague who is acutely intoxicated by alcohol or drugs and to simultaneously be responsible for providing patient care, it is important that learners are provided with formal instruction on how to recognize impairment and navigate the potentially difficult conversation with the impaired provider to ensure patient safety. This simulated scenario provides a realistic curricular instrument that could be implemented in any EM training program. Topics: Substance abuse; impaired provider; impaired provider reporting policies; professionalism; patient safety; provider safety.