Once upon a time, in a community ED far, far away, there was a hypotensive patient. The patient's pressure was plummeting, and Dr. Goldilocks was fretting. “Where's the epi drip?” Her team raced to set up the pump as the patient plunged perilously close to cardiovascular collapse. Finally, like a parachute just barely opening in time, the vasopressor drip began to infuse. “Wow,” exhaled Dr. Goldilocks. “Next time we need a temporizing measure.” Too slow.
Inspired by her critical patient, Dr. Goldilocks ventured into the forest of self-learning in search of best practices. She came upon an abandoned doctors' lounge. There were worn textbooks and a chair with so much dust that she knew she wasn't the only EP who never had time to sit. Dr. Goldilocks pulled Rosen and Tintanalli from the shelf.
“What would push-dose epinephrine be listed under?” she wondered. She thumbed through the indices, but could not find it. Then she noticed the copyright. “These books are almost a decade old!” she cried. “I can't find the newest research and innovations here. I'll be too slow to adopt new practices if I only use textbooks.” Too fast.
Dr. Goldilocks retrieved her smartphone from her pocket and began to wander through the wild expanse of information. She knew many residencies encouraged eager residents to unearth the treasures of FOAM (free open access medical education). So she too set off down the pathway of FOAM in hopes of finding clinical gems.
She was astounded by the stream of critical care resources at her fingertips. “Why have I been stuck on Facebook with people I already know when I could have been finding the people I should know on Twitter and getting helpful information?” she wondered. She came across the @FOAMstarter Twitter account, and saw a “following” list of 31 people active in FOAM. She followed them all.
She discovered links to blogs, podcasts, tweets, online videos, text documents, photographs, and Facebook groups. She discovered an online community of critical care friends from around the world. The people she'd seen on CNN, heard at conferences, and read in journals were online. Dr. Goldilocks read about recently published studies and new innovations.
She started to explore the push-dose pressor topic. “There are more than 100 FOAM-related citations about bolusing vasopressors in the ED!” Dr. Goldilocks watched an instructional video and prepared to start administering small doses of epinephrine and phenylephrine to future patients. “I've found my temporizing measure for hypotension!”
Getting to Just Right
Suddenly, concerns halted her enthusiasm. Amid the information stream were apprehensive voices. Acquisito, et al., claimed the prominence of ED push-dose pressors in FOAM was responsible for increased use and subsequent increased medication errors. (Am J Emerg Med 2017. doi: 10.1016/j.ajem.2017.06.013.) Dr. Goldilocks read about 50 mg of phenylephrine administered instead of the intended 50 micrograms, 1,000 micrograms of phenylephrine instead of 100 micrograms, and 1 mg of epinephrine instead of 5-20 micrograms. The authors pointed out confusion about preparation and dose in acute stressful situations. “Would that happen to me?”
Dr. Goldilocks was worried. One article seemed reassuring (Ann Emerg Med 2017. doi: 10.1016/j.annemergmed.2017.04.021) until she read that there were only two peer-reviewed articles on the topic, compared with more than 100 references on FOAM. She happened upon another article stating that FOAM has encouraged the use of bolus-dose vasopressors in the ED despite the paucity of published peer-reviewed evidence. FOAM is translating preliminary findings too quickly, disseminating ideas and new practices through social media before there is evidence to substantiate them. “Oh, no!” she screamed. “I'll be adopting new practices too quickly if I try everything I find on FOAM.” Just right.
“Textbooks are too slow. FOAM is too fast. Now what?” Still hungry for answers, she turned in exasperation back to her phone.
Scrolling out of the FOAM forest, a response to the article by Acquisito, et al., (Am J Emerg Med 2017. doi: 10.1016/j.ajem.2017.06.013) made her stop. Awad, et al., wrote that Dr. Acquisito's claim that FOAM contributed to push-dose pressor errors was purely anecdotal, without quantification of how many errors there were compared with how many times in total push-dose pressors were administered. (Am J Emerg Med 2017. doi: 10.1016/j.ajem.2017.08.006.)
There also was no quantification of actual use of FOAM resources by physicians involved in the errors. Awad, et al., made clear that anyone using FOAM would need methods of appraising FOAM resources, which were much like the methods of appraising traditional print publications. Dr. Goldilocks understood that what she found on FOAM required the same critical assessment, training, and practice she'd use for techniques described in print publications.”
It all fell into place as she read Dr. Acquisito's counter-response to Awad, et al. (Am J Emerg Med 2017. doi: 10.1016/j.ajem.2017.08.007.) Yes, their experience is anecdotal. Yes, push-dosing may be error-prone in acute situations because it lacks standardization. Maybe we should adopt push-dose pressors after more safety measures are in place. Maybe we should only use continuous dosing of pressors. Maybe, as is the classic conclusion of so many articles, “more studies are needed.” But the takeaway was that you need critical thinking to appraise the merits of any information, be it from FOAM or print publications.
In this age where ideas and research new to EM are instantly transferred to all of us, the potential to enhance patient care is right here online if we use it wisely. Stop. Listen. Research. Be critical. Decide if it works for your setting. Never take anything on faith or change medical practice based on tweets or podcasts. She knew that following FOAM plus doing her homework would let her adopt new practices not too fast or too slowly but at a pace that was just right. From that night on, Dr. Goldilocks used FOAM wisely, and she lived happily ever after. The end.
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