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Ouch! Shots fired! :P
I am sorry if the listener disliked the poison ivy episode, but let's look at a few points the listener made:
1) the data is of lower quality than what is typically in EMRAP.I started off by saying the evidence was based off a small study; and while it was not JAMA, there are many topics covered on this program that are not particularly based off much data - only glimpses into the mind of the great podcasters (like, say, Reuben waxing about Morphine IR, or, well, just about everyone talking push dose pressors... or the data on methotrexate toxicity... or even physician wellness!– not great data on any of these things, but they are discussed!) … If EMRAP only discussed items entrenched in solid evidence & well designed trials, this would be a much, much shorter podcast. Likewise, EMA actually discusses "food for thought" papers like this with some regularity.
2) The idea that we should let a disease run its course when potentially better options are available.Are we not all subscribers to this fine podcast to improve our care across the entire spectrum? If our junk gets poison ivy, do you *really* want to have to come back to the ED more than once? I also get that I probably should have mentioned considering doing a fingerstick prior to starting steroid tapers in select patient populations. One reason I really enjoy recording for EMRAP is to cover the non-resus stuff that we see all the time and thus we can improve the entirety of our EM game, as I'm sure EMRAP has many listeners who cover the spectrum of ED care, from fast track rashes at 2pm to the resus room at 3am plus everything in between. We should take pride in giving our all to each and every one of them, making the best judgements we can make with imperfect data..... thus, I thought it was only fair to provide better care to something we may see regularly during the summer outside of resus.
Also, for what its worth, in two out of three trials looking at steroids vs anti-histamines, steroids won, with the exception of one trial (with that one trial excluding 80% of patients) – and none of these trials explicitly looking at poison ivy.
Ultimately, I probably should have closed with offering some sort of shared decision making to the tune of, “you have a higher chance of resolving this faster without the need for additional medications with longer courses of steroids, but with a theoretical increased risk of side effects like an increased glucose level, etc. …. so tell me sir/madam, how bad is this rash bothering your junk?”
Thanks for the input & thanks for listening!Patrick
What you do matters.