Emergency Medical Minute

Contributor: Travis Barlock, MD
Educational Pearls:
 
First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma. 
Complication rate for patients intubated on the first pass is 14%

Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt

 
How to improve likelihood of first-pass success:
Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71%

Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study cites a success rate in these patients of 96% with a bougie, compared to 82% without

Use a Checklist mnemonic (SOAPME)

Suction – On, ready, and within reach

Oxygen – Patient is preoxygenated

Adjuncts – Oral/nasal adjuncts and BVM ready

Positioning - Patient positioned properly; consider obesity, using semi-Fowler/head-up positioning

Medications – Rapid sequence intubation (RSI), sedation, vasopressor, and other medications prepared as necessary

Equipment – Laryngoscope (blade), tube, bougie/stylet, syringe, scalpel/cric kit, others ready as necessary




References
Sakles, J.C., Chiu, S., Mosier, J., Walker, C. and Stolz, U. (2013), The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med, 20: 71-78. https://doi.org/10.1111/acem.12055

Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2023;389(5). doi:https://doi.org/10.1056/nejmoa2301601

Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496

‌Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278

Turner, Joseph S et al. "Feasibility of  upright patient positioning and intubation success rates At two academic EDs." The American journal of emergency medicine vol. 35,7 (2017): 986-992. doi:10.1016/j.ajem.2017.02.011

 
Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P
 
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Dan Orbidan, OMS-II and Dr. Travis Barlock, MD discuss a real out of hospital call. This episode covers the implications of a pharmacologically abnormal patient presentation and the pre and post hospital considerations for patient management and care.

Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.

Contributor: Aaron Lessen, MD
Educational Pearls:
 
UTIs are commonly seen in older women
We often see them taking long-term prophylactic antibiotics because of common recurrence.

Around 20-30% of older women who develop a UTI have a recurrence due to either diagnostic failure, treatment failure or non-compliance with treatment. 

UTI signs and symptoms
Burning sensation when urinating

Strong urge to urinate

Urinating often and passing small amounts of urine. 

Pelvic pain 

 
There are currently more guidelines and studies on treatments to prevent these recurrent UTIs in women that we can start in the Emergency Department.
Vaginal estrogen has been shown to significantly reduce this issue of recurrence.

Very simple prescriptions can be prescribed in the ED

It has little systemic absorption and is generally very safe and effective.

 
References
Wells BA, De EJB, Visingardi J, Feustel PJ. IP15-36 IMPACT OF VAGINAL ESTROGEN ON SERIOUS ADVERSE OUTCOMES IN POSTMENOPAUSAL WOMEN WITH RECURRENT URINARY TRACT INFECTIONS: A RETROSPECTIVE STUDY. Journal of Urology [Internet]. 2025 May 1;213(5S):e778. Available from: https://doi.org/10.1097/01.JU.0001109984.67114.74.36

Ackerman AL, Bradley M, D'Anci KE, Hickling D, Kim SK, Kirkby E. Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). J Urol. 0(0). doi: 10.1097/JU.0000000000004723

Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589

Meister MR, Wang C, Lowder JL, Mysorekar IU. Vaginal Estrogen Therapy Is Associated With Decreased Inflammatory Response in Postmenopausal Women With Recurrent Urinary Tract Infections. Female Pelvic Med Reconstr Surg. 2021 Jan 1;27(1):e39-e44. doi: 10.1097/SPV.0000000000000790. PMID: 31725016; PMCID: PMC7737516.

Nazarko L. Recurrent lower urinary tract infection in older women [Internet]. Urology & Continence Care Today. Available from: https://www.ucc-today.com/journals/issue/launch-edition/article/recurrent-lower-urinary-tract-infection-in-older-women-ucct

 
Summarized by Aaryn David & Ahmed Abdel-Hafiz | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Aaron Lessen, MD
Educational Pearls: 
Back pain is a common presenting complaint in the emergency department.

Challenges arise when tailoring care to elderly populations using standard medical therapy:

Muscle relaxants carry the risk of CNS depression or anticholinergic effects such as urinary retention and confusion.

Pain medications such as opiates have side effects including constipation, respiratory depression, and hypotension.

NSAIDs carry a risk of GI bleeding and worsening kidney function with chronic use.

A randomized clinical trial assessing the effects of acupuncture on low back pain took 800 adults aged 65 and older with chronic low back pain and placed them into one of three treatment arms:

Usual medical care

Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus usual medical care

Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus 4-6 maintenance sessions during the next 12 weeks, plus usual medical care

Using the Roland-Morris Disability Questionnaire (RMDQ) score, they assessed disability at 6 months and 12 months.

The study found that those who had undergone treatment with acupuncture had significantly greater improvements in disability related to low back pain compared to the group that was only treated with usual medical care.

Acupuncture is not used in the ER, but could represent a relatively safe adjunctive therapy for patients who are not responding to standard medical therapy alone.

 
References: 
American College of Surgeons Committee on Trauma. Best practices guidelines: geriatric trauma management. American College of Surgeons; 2023. Accessed May 27, 2026. https://www.facs.org/media/ubyj2ubl/best-practices-guidelines-geriatric-trauma.pdf

DeBar LL, Wellman RD, Justice M, et al. Acupuncture for chronic low back pain in older adults: a randomized clinical trial. JAMA Netw Open. 2025;8(9):e2531348. doi:10.1001/jamanetworkopen.2025.31348

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P