AEM Early Access

AEM Early Access 17: Post-Traumatic Symptoms and Acute Pain Following Injury

Welcome to the seventeenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING: (OPEN ACCESS THROUGH JULY 31, 2018; CLICK ON TITLE TO ACCESS.)

The Association between Daily Posttraumatic Stress Symptoms and Pain over the First 14‐days after Injury: An Experience Sampling Study. Maria L. Pacella PhD,  Jeffrey M. Girard MS,  Aidan G.C. Wright PhD,  Brian Suffoletto MD, Clifton W. Callaway MD,PhD.

listen now: author interview with Dr. maria pacella

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Maria Pacella, PhD

Research Assistant Professor

Department of Emergency Medicine

University of Pittsburgh

article abstract:

Objectives
Psychosocial factors and responses to injury modify the transition from acute to chronic pain. Specifically, posttraumatic stress disorder symptoms (PTSS; reexperiencing, avoidance, and hyperarousal symptoms) exacerbate and co‐occur with chronic pain. Yet no study has prospectively considered the associations among these psychological processes and pain reports using experience sampling methods (ESM) during the acute aftermath of injury.

This study applied ESM via daily text messaging to monitor and detect relationships among psychosocial factors and post‐injury pain across the first 14‐days after emergency department (ED) discharge.

Methods
We recruited 75 adults (59% male; M age = 33) who experienced a potentially traumatic injury (i.e., involving life threat or serious injury) in the past 24‐hours from the EDs of two Level 1 trauma centers. Participants received 5 questions per day via text messaging from Day‐1 to Day‐14 post‐ED discharge; three questions measured PTSS, one question measured perceived social support, and one question measured physical pain.

Results
Sixty‐seven participants provided sufficient data for inclusion in the final analyses, and the average response rate per subject was 86%. Pain severity score decreased from a mean of 7.2 to 4.4 over 14 days and 50% of the variance in daily pain scores was within‐person. In multilevel structural equation models, pain scores decreased over time, and daily fluctuations of hyperarousal (b = 0.22, 95% CI [0.08, 0.36]) were uniquely associated with daily fluctuations in reported pain level within each person.

Conclusions
Daily hyperarousal symptoms predict same‐day pain severity over the acute post‐injury recovery period. We also demonstrated feasibility to screen and identify patients at risk for pain chronicity in the acute aftermath of injury. Early interventions aimed at addressing hyperarousal (e.g. anxiolytics) could potentially aid in reducing experience of pain.

ADDITIONAL READING:

Bryant, R.A., et al., The psychiatric sequelae of traumatic injury. American Journal of Psychiatry, 2010.

Gatchel, R.J., et al., The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull, 2007. 133(4): p. 581-624.

Rosenbloom, B.N., et al., Predicting pain outcomes after traumatic musculoskeletal injury. Pain, 2016. 157(8): p. 1733-1743.

O'Donnell, M.L., et al., Disability after injury: the cumulative burden of physical and mental health. J Clin Psychiatry, 2013. 74(2): p. e137-43.

Feinberg, R.K., et al., Stress-related psychological symptoms contribute to axial pain persistence after motor vehicle collision: path analysis results from a prospective longitudinal study. Pain, 2017. 158(4): p.682-690.

Price, M., et al., A feasibility pilot study on the use of text messages to track PTSD symptoms after a traumatic injury. Gen Hosp Psychiatry, 2014. 36(3): p. 249-54.

AEM Education and Training 05: Point of Care Resource Use in the ED: A Developmental Model

Welcome to the fifth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING: (click on title for full text article)

Point of Care Resource Use in the ED: A Developmental Model. Catherine Patocka, MDCM, MHPE, Michelle Lin, MD, Jeremy Voros, MD, and Teresa Chan, MD, MHPE

LISTEN NOW: AUTHOR INTERVIEW WITH DR. CATHERINE PATOCKA

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Catherine Patocka MDCM, MHPE, FRCPC (EM)
Clinical Assistant Professor in the Cumming School of Medicine, University of Calgary
Emergency Physician in the Calgary Zone

 

 

ARTICLE ABSTRACT:

Background
Technologic advances, free open‐access medical education (FOAM or #FOAMed), and social media have increased access to clinician‐oriented medical education resources and interactions at the point of care (POC); yet, how, when, and why medical providers use these resources remains unclear. To facilitate the development and design of intuitive POC resources, it is imperative that we expand our understanding of physician knowledge‐seeking behavior at the POC.

Methods
Individual semistructured interviews were conducted and analyzed using a qualitative, grounded theory approach. Twelve emergency medicine providers (three medical students, three residents, and six attending physicians) were interviewed in person or via video chat to explore how POC resources are used in the emergency department (ED). A coding system was developed by two investigators and merged by consensus. A third investigator audited the analysis.

Results
A conceptual framework emerged from the data describing the four main uses of POC resources (deep‐dive, advanced clinical decision making, teaching patients, and teaching learners) and how practitioners’ main use varied based on medical expertise. Junior learners prioritize their own broad learning. Experienced learners and physicians prefer to 1) seek answers to specific focused clinical questions and 2) disseminate POC information to teach patients and learners, allowing them to devote more of their time to other clinical and teaching tasks.

Conclusion
The conceptual framework describes how physician knowledge‐seeking behavior using POC resources in the ED evolves predictably throughout training and practice. Knowledge of this evolution can be used to enhance POC resource design and guide bedside teaching strategies.

RESOURCES MENTIONED IN PODCASt:

a) Googlefoam.com: a FOAMed search engine

b) DrawMD (ios apps, website) for patient teaching

c) PediStat app by QxMD: bedside pediatric acute care reference

d) RxTx mobile (ios app) from the Canadian Pharmacists Association

e) OB Wheel app (multiple versions available)

f) ALiEM Cards (previously PV Cards)

AEM Early Access16: Patients' Perceptions of Shared Decision Making in the ED

Welcome to the sixteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

AEM Podcasts logo[3].png

DISCUSSING (OPEN ACCESS THROUGH JULY 31, 2018; CLICK ON TITLE TO ACCESS)

A Qualitative Analysis of Patients’ Perceptions of Shared Decision Making in the Emergency Department: “Let Me Know I Have a Choice”
Elizabeth M. Schoenfeld MD, MS  Sarah L. Goff MD  Gwendolyn Downs DO  Robert J. Wenger DO Peter K. Lindenauer MD, MSc  Kathleen M. Mazor EdD

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. SCHOENFELD

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Elizabeth M. Schoenfeld MD, MS

Assistant Professor, Department of Emergency Medicine

Institute for Healthcare Delivery and Population Science

UMASS Medical School - Baystate

Adjunct Faculty, Tufts School of Medicine

ABSTRACT:

Background and Objectives
Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients’ perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients’ desired level of involvement and what barriers and facilitators patients find most relevant to their experience.

Methods
We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three‐person coding team. Emergent themes were identified, discussed, and organized.

Results
Twenty‐nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self‐efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians’ good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care.

Conclusions
This exploration of ED patients’ perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.

ADDITIONAL READING:

Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, et al. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Annals of Emergency Medicine. 2017 Nov;70(5):688–95. 

Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, et al. A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. Journal of Graduate Medical Education. 2018 Feb;10(1):43–50.