R&R In The FASTLANE 191

Welcome to the 191st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

ART Trial Investigators. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017; 318(14):1335-1345. PMID: 28973363

• A multi-center non-blinded randomised controlled trial that found higher mortality in patients with moderate-to-severe ARDS who received an open lung ventilation strategy compared with those who got ARDSNet-style protective lung ventilation. The open lung approach involved higher PEEP settings and the use of a staircase recruitment manoeuvre. Questions remain about the external validity of the study and whether we can identify subgroups of patients who might benefit. Nevertheless, ART is a real shake up for ‘open lung’ practitioners.
• Recommended by: Chris Nickson

Roldan CJ, et al. Randomized Controlled Double-blind Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. Academic emergency medicine. 2017; 24(11):1307-1314. PMID: 28646590

• This is a teeny tiny RCT of ED patients with previously diagnosed gastroparesis treated with either haloperidol 5 mg IV or placebo, in addition to conventional therapy (which were mostly PPIs, ondansetron, opioids, and metoclopramide and similar between groups). The mean pain score dropped by 5.37 in the haloperidol group compared to 1.11 in the placebo group, which was statistically significant. This is by no means a definitive trial but is a piece of literature in line with the current practice of many to give haloperidol to patients with this frustrating diagnosis (and may help with opioid sparing, although this is yet to be proven)
• Recommended by: Lauren Westafer
• Further reading: Gastroparesis – I Feel Like Throwing Up (The SGEM)

Rosenbaum L. The Less-Is-More Crusade – Are We Overmedicalizing or Oversimplifying? The New England journal of medicine. 2017; 377(24):2392-2397. PMID: 29236644

• Although I disagree with many of the individual points raised, the overall message of this essay is good: medical care is incredibly complex and all too often our conversations about it (and those of policy makers) are oversimplified. On the whole, I think it’s is clear that we are doing far too much in medicine; that over-treatment and over-diagnosis are far bigger problems than under-treatment and under-diagnosis. However, the author is spot on when she says, “the most accurate conclusion is that sometimes less is more, sometimes more is more, and often we just don’t know”. This article has spawned a lot of controversy. It is worth reading to understand why.
• Recommended by: Justin Morgenstern

Samuels EA, et al. “Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients. Annals of emergency medicine. 2017. PMID: 28712604

• This is a qualitative study of transgender patients who visited an ED in the US. This article is a must read as providers often lack insight into the complexities of caring for transgender patients and systemic barriers to conscientious care. This article points to some things providers can change immediately including proper use of pronouns, comfort with inquiring about gender identity, lack of understanding of medical issues related to transgender health, and unfortunately intentional and unintentional shaming or disrespect. Other issues need systemic reform, such as reconciliation of sex and gender identity in EMRs and hospital bracelets and lack of privacy in crowded EDs.
• Recommended by: Lauren Westafer
• Further Reading: The Transgender Patient + more from ACEP (FOAMCast)

Holden D et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Ann Emerg Med 2017. PMID: 28601272

Cole JB. Bolus-Dose Vasopressors in the Emergency Department: First, Do No Harm; Second, More Evidence Is Needed. Ann Emerg Med 2017 PMID: 28754354

• The use of push-dose pressors has gained steam over recent years. This article is an excellent review of the reasons for use, the pharmacology of different agents as well as the scant literature investigating their use. An accompanying editorial calls for a systematic approach to research on the intervention simultaneously raising the issue of knowledge translation via social media based on expert recommendations. While the caution expressed by the authors is important, we must also ask whether withholding the treatment while awaiting a large randomized double-blind control trial that will likely never happen is responsible.
• Recommended by: Anand Swaminathan
• Further Reading: Sept 2017 Journal Club (BroomeDocs)