Informed consent for invasive procedures in the emergency department.

BACKGROUND: Informed consent for procedures in the emergency department (ED) challenges practitioners to navigate complex ethical and medical ambiguities. A patient's altered mental status or emergent medical problem does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced assessment of the situation to determine the appropriate level of participation. Given the complexities involved with informed consent for procedures in the ED, it is important to understand the experience of key stakeholders involved. METHODS: For this review, we searched Medline, the Cochrane database, and Clinicaltrials.gov for studies involving informed consent in the ED. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data was extracted from included studies: Title, authors, date of publication, study type, participant type (i.e. adult patient, pediatric patient, parent of pediatric patient, patient's family, or healthcare provider), number of participants, and primary outcomes measured. RESULTS: Fifteen articles were included for final review. Commonly addressed themes included medical education (7 of 15 studies), surrogate decision-making (5 of 15 studies), and patient understanding (4 of 15 studies). The least common theme addressed in the literature was community notification (1 of 15 studies). CONCLUSIONS: Studies of informed consent for procedures in the ED span many aspects of informed consent. The aim of the present narrative review is to summarize the work that has been done on informed consent for procedures in the ED.

Public interest in gun control in the USA.

To characterise public interest in gun control in the USA using internet search queries, we undertook a cross-sectional study of the relative popularity Google Trends searchers for 'Gun Control', 'Second Amendment', 'National Rifle Association' and 'Mass Shooting' from May 2015 to December 2018. 740 weeks of data were queried. Graphed data revealed nine major inflection points. Seven of the nine (78%) major inflection points were associated with mass shootings, while two of the nine (22%) were related to political events by either the president of the USA or a presidential candidate. Our exploration of Google Trends shows the frequency of national searches related to gun control peaks with mass shootings over a 1-2-week period and then stabilises to nominal relative popularity thereafter suggesting a need to engage the public on gun control during 'trough' periods in order to sustain national interest and dialogue.

Financial relationships with industry among guideline authors for the management of acute ischemic stroke.

OBJECTIVE: To characterize the prevalence of industry relationships among authors of acute ischemic stroke (AIS) guidelines and its association with graded evidence. METHODS: A cross-sectional study of five policy papers on AIS published by the American Heart Association (AHA)/American Stroke Association (ASA), American Academy of Emergency Physicians (AAEM), and American College of Emergency Physicians (ACEP). Financial conflicts of interest (FCOI) data were obtained using the Open Payments Database for the years 2013 through 2017. A search of publicly available information was done to determine post-guideline employment. We characterized the prevalence of FCOI, as well as employment with industry engaged in thrombolysis or neurointerventional treatment of AIS after guideline publication. RESULTS: 76 unique authors were identified in 5 policy statements. The prevalence of FCOI among authors of AAEM, ACEP, and AHA/ASA guidelines was 0%, 0%, and 35%, respectively. Post-publication increase in FCOI was 0% for authors of the AAEM and ACEP guidelines, and a 300% increase for authors of the 2013 AHA/ASA guidelines with data unavailable to assess post-publication FCOI for authors of the 2018 AHA/ASA guidelines. 2 authors were found to engage in new industry employment following recommendation publication. Finally, 9% (n = 3) authors of the 2013/2018 AHA/ASA guidelines were employees of the Genentech Speakers Bureau. CONCLUSIONS: Our results suggest an association between current Graded Evidence and FCOI of major academic societies for the management of AIS. Due to the bias inherent to such conflicts, future recommendation groups should take steps to insulate against FCOI both during and following guideline publication.

Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation.

BACKGROUND: Current guidelines for the treatment of adult patients in cardiac arrest are supplied by the American Heart Association through basic life support and advanced cardiovascular life support (ACLS) provider courses. When treatments defined by the ACLS guidelines are unsuccessful in terminating a lethal dysrhythmia, the use of alternative strategies may prove useful. In this case, two defibrillators were used to deliver a greater than normal energy waveform over an extended time interval to return a patient to a normal sinus rhythm. CASE REPORT: A 56-year-old woman presented to the emergency department with complaints of chest pain, nausea, and vomiting. The patient's initial work-up, including an electrocardiogram and cardiac troponin, did not show evidence of acute ischemia, and she was admitted to the observation unit for further evaluation. While in the emergency department, the patient developed ventricular fibrillation, and ACLS was initiated. After four unsuccessful defibrillation attempts, a second defibrillator was placed on the patient, and the two were activated almost simultaneously. The patient had immediate return of spontaneous circulation, underwent cardiac catheterization, and was discharged home 1 week later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case shows that dual sequential defibrillation may be a successful method for terminating refractory ventricular fibrillation. Further investigation on cardiac resuscitation should be conducted to standardize the dual sequential defibrillation delivery procedure. Until such guidelines are established, physicians should take this treatment into consideration when standard ACLS measures have failed to successfully terminate refractory ventricular fibrillation.

FOAM Impact: The Influence of Open-access Medical Education on Practice Uptake.

OBJECTIVES: The FOAM Impact study sought to examine baseline rates of intravenous (IV) lidocaine usage for the treatment of renal colic and to compare rates of use between FOAM utilizers and nonutilizers. We sought to measure the effect of FOAM resources on clinical practice by timing the release of FOAM content with publication of the LIDOKET trial. METHODS: A cross-sectional before-and-after survey was conducted and disseminated on two social media platforms. The 13-question, anonymous survey was posted for 1 week prior following the release of the LIDOKET study. Descriptive statistics, Mann-Whitney t-test, and chi-square test statistics were used to describe survey respondent characteristics and Likert responses. RESULTS: There were a total of 472 survey respondents. A total of 321 physicians (75.7% of total respondents) provided pre- and postpublication survey answers. There was no significant change in the use of analgesics before and after publication of LIDOKET and concurrent REBEL EM blog post. A total of 197 (42%) survey respondents reported using lidocaine for renal colic, of which 60 respondents (13%) reported frequent or occasional use. The mean difference in perceived efficacy of lidocaine before and after publication was -0.30 (95% confidence interval [CI] = -0.80 to 0.19, p = 0.15). Being a FOAM user was not associated with changes in mean difference in perception of lidocaine efficacy (F = 0.127, p = 0.72); however, there was a significant difference in perception of lidocaine's efficacy following LIDOKET and REBEL EM publication (F = 4.718, p = 0.03). CONCLUSIONS: Using an online survey-based technique, no appreciable impact of FOAM resources was immediately apparent; however, engagement with FOAM was associated with a change in perception of IV lidocaine's efficacy. To our knowledge, this is the first study of its kind to evaluate the impact of FOAM on clinical practice. The unique method of coordinating FOAM distribution with traditional medical publication may provide future opportunities for measuring the impact of asynchronous medical education resources on medical practice.