August 2021

Clinical Question

Does listening to a medical podcast while driving influence the knowledge you retain?

Title of Paper

[Maximizing the Morning Commute: A Randomized Trial Assessing the Effect of Driving on Podcast Knowledge Acquisition and Retention]

Journal and Year

Annals of Emergence Medicine. 2021.

Lead Author

Michael Gottlieb.

Background

– 90% of EM residents reportedly listen to podcasts on a regular basis
– 100% of you listening now have listened to a medical podcast
– Most of us perform other tasks while listening (driving, exercising, cleaning, etc)
– Does this take away from what we’re learning?

Study Design

– Multicentre, randomised, crossover trial comparing knowledge acquisition and retention while driving compared to being seated in a room
– Conducted at 4 emergency medicine residency program sites in the US

Subjects – Studied

– All interested EM residents (PGY1-4) (paid $75 to participate)
– Excluded:
– Can’t drive / no car
– Haven’t previously listened to a podcast while driving

Intervention

– Listen to medical podcast while driving (continuous) for 30 minutes

Control

– Listen to same medical podcast while seated at home and without concurrently performing other activities

Cross-over

– Driving group immediately swapped to control and listened to another podcast
– Control group swapped to driving and listened to the other podcast
– No washout period – topics different

What they did

– Blinding:
– Subjects blinded to hypothesis – but they were aware they would take a delayed recall test
– Podcast:
– Discussion of 5 papers (basically an edited episode of EMA)
– Ensured articles hadn’t been included in their hospital teaching / journal clubs or featured in FOAMed articles.
– Tests:
– Immediate recall: 20 item test within 30 minutes (one test for each podcast)
– Delayed recall: 40 item test completed 1 month later (testing both podcasts)
– Tests sound like they were carefully drafted in a well standardised way by experienced EPs and were tested for their consistency.

Outcomes

– Performance in immediate and delayed recall tests

Summary of Results

– 100 residents
– 96 completed delayed recall assessment
– Immediate recall: **No difference**
– Driving 74.2% | Control 73.3%
– Delayed recall: **No difference**
– Driving 52.2% | Control 52.0%
– Mean drop in score: **No difference**
– Driving 22.0% | Control 21.6%
– Perceived (self-reported) knowledge retention: 6.5% difference [95%CI 3.5-9.5%]
– Driving 63% | Control 70%

Authors Conclusion

This randomised, multicentre crossover study demonstrated that listening to podcasts while driving did not reduce immediate knowledge acquisition or delayed knowledge retention when compared with listening while seated and undistracted. Educators may consider podcasts as an efficient instructional resource that can be utilised during semiautomated activities like driving. Future research should examine the effect of podcast listening on driving quality.

Clinical Bottom Line

Good news for RCEMLearning listeners! You might recall half of what you hear today in a month’s time.

In my opinion – podcasts such as ours aren’t aiming for you to have 100% retention. We’re here to point you to things we find interesting, that you may want to go and read for yourself. And since you’re not taking part in a randomised study, you can always listen to us again…and again…and again…you lucky devils.

Other #FOAMed Resources / References:

Chris Connolly pointed us to this one having found it on the ever-on-the-ball journalfeed

Authors

Andy Neill
Dave McCreary

Clinical Question

– can we use migraine meds in post traumatic headache?

Paper

– Randomized Study of Metoclopramide Plus Diphenhydramine for Acute Posttraumatic Headache

Author

– Friedman, Neurology, Mar 2021

Background

– headache is common after concussion. And there is lots out there on diagnosis and prognosis and return to play. And while there’s lots of emphasis on rest there is not anything particular on analgesia and headache is a dominant and often disabling symtpom for these folk.

– by now we’re quite good at managing migraine in the ED, or rather we have lots of good data supporting best practice even if it’s not actually done.
– these guys have combined what we know about migraine treatment with post traumatic headache to see if we can treat the pain

Methods

– randomised double blind, ED based trial of IV metoclopramide and diphenhydramine for headache after head injury
– used the International Classifcation of headache disorders criteria (the same people who make criteria for migraine) to pull out those with post traumatic headache (importantly this is meant to exclude other potential headache diagnoses)
– unclear if this could people in the ED for their first head injury presentation or those who bounced back with symptoms
– the metoclopramide was dosed at 20mg (whih might be more than you normally give but has been studied lots of times and is perfectly safe). the diphenhydramine is an antihistamine used here prophylactically for the akathisia type symptoms that metoclopramide commonly brings on.
– primary outcome was pain on a 0-10 scale at 60mins after drug

Results

– stopped early due to COVID-19 but only 2 short of their target of 162
– middle aged with more female than men with an average of 30 hrs post onset.
– everyone got better with placebo having a 3.8 point improvement and the intervention combo having a 5.2 point improvement. this buys them a 1.4 point difference over placebo and fits nicely into their stats
– lots more rescue meds in the placebo group

Thoughts

– yes this works but placebo is a very low bar to get over
– would be lovely to see how this compares to an NSAID or even just paracetamol
– there probably is some cross over amongst migraines and tension and traumatic headaches in terms of pathophys as dopaminergic agents work for all of them.
– it’s nice to have this as another option as these symptoms are highly debilitating and anxiety provoking.

Via spoonfed EM by Aaron Lacy

This month Chris and Becky are looking at the updated RCEM clinical standards and guidance on pain management in the ED.

This is a really important and really common problem in the ED. Think about how many of your patients are in ED because of pain?!

First pearl is that the well recognised pain scores have not been validated in ED patients, that being said they are still probably useful as they allow sequential scoring of pain, so don’t throw them in the bin yet!

There are some potential barriers to good pain management in the ED and the table from the guideline discusses some of them.

We like a traffic light system in the ED and again the guideline has a great table outlining how and when pain relief should be offered. The table here can be a great point of reference. The key is identifying the patient in pain, staging an intervention and then CHECK IT WORKED!!!!

Some special considerations when choosing pain relief.
1: Elderly and frail patients. Consider the dose of paracetamol when the patient is less than 50kg. Remember NSAIDS have a significant side effect profile and many contra indications.
2: Pregnant patients. Remember prescribing recommendations in pregnancy are often to do as little as possible. Paracetamol is ok. Opiates are ok except in labour.
3: Drug seekers. This is hard and a divisive topic but Becky and Chris agree its best to take patients at face value and treat their pain. Don’t let your bias influence your decision making.
4: Remember other analgesic interventions such as blocks, splinting, reduction and Charlotte’s favourite – hypnosis!

Reference

rcem.ac.uk

Authors

Andy Neill
Dave McCreary

Clinical Question

– how often does awareness occur following RSI in the ED

Paper title

– The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department

Author

– Pappal, Annals EM 2021

Background

– NAP 5 was a large audit project in the UK that looked at awareness during elective anaesthesia. It highlighted that this happens in ~1:20000 anaesthetics but more like 1:8000 when NMB are used
– the idea of being paralysed and awake is frankly slightly terrifying especially if someone is performing some horrible painful procedure at the same time
– so the quesiton arises – does this happen to patients in the ED? This is not something that is often high in our priority list given that we’re a little busy trying to keep them alive
– indeed our current RSI strategy leans towards heavy on the paralytic and low on the sedative to ensure haemodynamic stability and optimised laryngoscopy. Prior studies have also shown big delays in initiation of post intubation sedation, so this seems to be a perfect storm for awareness
– against that is the fact that many of the patients we intubate are already unconscious or at the very least altered in their conscious levels so maybe it’s not so big a deal.
– this study gives us an answer

Methods

– single centre in the US
– consecutive patients 24 hrs a day who were tubed in the ED, these could be people intubated in the ED or people who arrived intubated
– excluded neurological diagnoses (eg TBI)
– primary outcome was awareness with paralysis. now this raises a key issue as in critical care we encourage light sedation and patients responding to us while intubated. So memories of being aware are not necesarily bad but for this study awareness with paralysis was the key thing and they used a special validated questioing tool to work that out.

Results

– 380 pts over a year
– 7% screened +ve for some kind of wakeful paralysis and when looked at in detail they claim that 2.5% had awareness (for example some who claimed this had not actually received any NMB). This is roughly 1:40
– there is some lovely qualatative data from the patients.
“I came to the [ED] because my tongue was swollen. I remember them putting the breathing tube down, but I could not move. I remember the breathing tube actually going in and being panicked. It was terrible and traumatic. I was panicking inside. Then I went to sleep.”
– ketamine and etomidate were commonly used and that’s not to say that those drugs are causative here, just that that is common practice in that depatment

Thoughts

– great study, important question. We cannot just blow if off and pretend it’s not our problem as it clearly is.
– I know we have a lot of priorities all at the same time with someone this sick in the ED but this must be one of them. I have seen post intubation sedation on RSI checklists as a good way to make sure the propofol or whatever infusion is drawn up and ready to go
– i know my own personal practice is once the tube is in and you can see that patient has tolerated the sedatives and the switch to poitive pressure then i’ll often use up the rest of the sedatives i have drawn up just to tide things over till the infusion is running
– having worked on both sides of the ED/ICU divide i see a lot of cricicsm against ED practiicioners about the lack of post intubation sedation but it also happens when the ICU team lead the RSI in the ED and it also happens in the ICU.