IV subdissociative dose ketamine (SDK) is used with increasing frequency for acute pain management in the ED. However, most studies have excluded older adults in assessing its efficacy and safety. In this episode, Sergey Motov (@painfreeED) discusses his recent paper “Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial” published in the American Journal of Emergency Medicine in May 2018.
UTIs, UICs, and CAUTIs in older adults! In this episode, Mary Mulcare, EM and geriatric-EM-trained physician in NYC and I discuss how to diagnose UTIs in older adults, and the confounding factors of asymptomatic bacteriuria, sterile pyuria, and colonization. We discuss how to diagnose a UTI, how to pick medications, dos and don’ts of when to place a urinary catheter, and how to create a protocol at your institution to reduce IUCs and CAUTIs. You may think this topic is simple, cut, and dry, but it is not. Treating a non-existent UTI can do harm, because of all the side effects of medications. But not treating a true UTI can also do harm, as it can lead to sepsis. Placing urinary catheters sometimes is absolutely required, and other times is less clear. It too has risks and benefits. Particularly in frail elderly patients, UTIs and also IUCs can lead to delirium and deconditioning.
Older adults who suffer traumatic injuries have worse outcomes than younger patients. In this episode Dr. Zara Cooper (acute care and trauma surgeon at Brigham and Women’s hospital) and I discuss some of the reasons for this, and also ways to avoid missing injuries in older adults. Falls are the most common cause of trauma in older patients, and understanding how falls are a geriatric syndrome can help you understand how to help prevent future falls.
The way we currently provide geriatric emergency care is not sustainable. With the growing aging population, the dwindling medicare dollars, and the recognition that we need to improve the quality of geriatric care, we have to find ways to transform the systems in which we care for our older patients. Now there is a new step forward in this direction: EDs around the country can become accredited through ACEP as a Geriatric EDs (or geriatric-friendly ED) at three different levels. This accreditation is setting a new standard for geriatric care and for what it means to be a geriatric ED (GED). The accreditation is set up to work for any hospital from the smallest, rural ED, to a large, urban center with its own, separate GED space. Chris Carpenter, a major force behind the GED guidelines and accreditation, talks with me about why this is important, why you should care, and responds to potential criticisms and concerns.
The risk of falls increases as we age. Unfortunately, so does the risk of injury, morbidity, and mortality following a fall. Falls risk is considered a geriatric syndrome, with multi-factorial causes. Falls are a the #1 cause of trauma-related mortality in older adults, and a major cause of ED visits, hospital admissions, and admission to nursing facilities. Often, a patient at high risk for falls is not identified until after they have suffered an injury. Orange County EMS developed a system to help identify patients who were at high risk for falls, perform a comprehensive home visit, and connect those individuals with appropriate services to help reduce the rate of future falls and help those patients maintain their independence and functionality in their home environment.
ACEP’s 2013 Choosing Wisely campaign identified engaging palliative care or hospice services in the ED as one of their 10 recommendations. Palliative care can help with symptom management, support families and patients, and help clarify their goals of care. Most EDs, however, do not have real-time palliative care consults available at all times, or at all! So the emergency physician is usually the person providing palliative care for patients in the ED. In this episode Alisha Benner discusses what palliative care is and shares pearls for better symptom management, communication with patients, and active management at the end of life.
This is a continuation of our discussion of Eye Emergencies in the elderly with ophthalmologist and retina specialist, Dr. Bryan Hong. Many thanks to the Life in the Fast Lane blog for including eye emergencies part 1 in their LITFL Weekly Review!
Eye concerns are a common reason for elderly patients to visit the ED. Their causes can range from benign to serious, time-sensitive, vision-threatening entities. In this episode, ophthalmologist and retina-specialist Dr. Bryan Hong talks us through his approach and initial management of four common ophthalmologic emergencies.
The number of new oral anticoagulants has grown dramatically in the last few years. And with that growth has come the need for new reversal agents. Reversing anticoagulation in patients with acute intra-cranial hemorrhages can be complex and dependent on what medication your hospital stores. It is important to know what is out there, what you can use, and how effective it is likely to be.
Elder abuse is a common and under-recognized problem among older adults. In the Emergency Department, we are uniquely positioned to identify patients who may be at risk. In this episode, Tony Rosen (https://weillcornell.org/anthonyrosen), an Emergency Physician and researcher with fellowship training in Geriatric Emergency Medicine, who works at Cornell in NYC discusses what constitutes elder abuse, its prevalence, how to identify it, and what to do when you suspect it.
