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EM Lyceum - A Novel Method
to Encourage Academic Debate
and Teaching Amongst Faculty
and Residents
Whitney K. Bryant, MD, MPH
Anand Swaminathan, MD, MPH
Disclosures
What the hell is a Lyceum?
The Reality
 Clinical shifts, especially in most over-extended
academic EM centers, are chaotic
 The practice of EM varies widely from hospital to
hospital, and even attending to attending within a
residency program
 The balance of education versus service can feel
skewed for residents
The Goal
 Incorporate evidence-based teaching and nuanced
academic debate into the clinical environment
 Ensure uniform resident exposure to this, even if
“off-service” that month
 Promote relevant, enjoyable, and succinct faculty
teaching during shifts
The Curriculum
 Developed in collaboration between residents and
faculty at Bellevue/NYU Hospital Center
 Controversial topics in EM chosen
 Can be used to start resident-initiated debate, as a
background for mini-lectures, or as a stand-alone
lesson plan.
Curriculum Logistics
 Curriculum team discusses potential topics and
questions, reviewing the literature for areas of
practice variation or deviation from evidence-based
practice
 New Topic Roll Out – 1st Wednesday of the month
 Questions and key articles sent to attendings the
Sunday before
Curriculum Logistics
 Posters placed in all clinical areas
 Residents encouraged to discuss questions with
attendings, empowering and enlisting them to pilot
their own education
POSTERS
Acute Coronary Syndrome
1. What anti-coagulants and/or anti-platelet agents do you
use in a patient with a STEMI? In an NSTEMI?
2. How do you identify and manage patients with unstable
angina?
3. How do you risk stratify patients with chest pain? Do you
use any clinical decision rules?
4.
How reassuring is a recent (< 1 year) negative
stress test in managing a patient with chest
pain? How about a recent “normal” cath (i.e.,
< 30% blockage, no intervention)?
Hyperkalemia
1. What are the EKG changes associated with hyperkalemia?
Do these changes occur in a predictable order?
2. What is the role of kayexylate in the treatment of
hyperkalemia?
3. Is there a threshold serum potassium level or EKG finding
that triggers you to administer calcium? How do you give
calcium when you use it?
4. When do you re-dose patients after treating them for
hyperkalemia?
“ANSWERS”
“Answers”
 Look for as much high quality evidence as we can
find
 Create “answers” based on the best evidence and
group consensus
 Where there is minimal evidence, we use expert
opinion
 Distributed via email and in conference
What is the role of Kayexalate in
the treatment of hyperkalemia?
 Kayexalate (Sodium Polystyrene Sulfate) is a cationexchange resin that was approved in 1958 as a
treatment for hyperkalemia. It is believed to help
exchange sodium for potassium in the colon and
thus encourage excretion of potassium from the
body.
 Although this drug has been used for a number of
years as an adjunct to more acute treatments, there
are two potential problems with its use.
What is the role of Kayexalate in
the treatment of hyperkalemia?
 Firstly, there is little to no evidence that Kayexalate effectively
reduces serum potassium levels. The two original studies
promoting its use, often cited in literature, were published in
the New England Journal of Medicine in 1961. These two trials
were completed without any controls, multiple confounding
variables, a lack of statistical analysis, and demonstrated
minimal if any effect of Kayexalate on serum potassium levels
(Scherr, 1961 & Flinn 1961).
 Furthermore, a recent study in 1998 also failed to demonstrate
a statistically significant difference in serum potassium levels
at 4, 8, and 12 hours after administration of 30g Kayexalate
with sorbitol, compared to controls (Gruy-Kapral, 1998).
Discuss the Utility of
Pretreatment Agents in RSI.
 Atropine: This drug is most commonly used in pediatric
patients (particularly < 2 years of age) to attenuate reflex
bradycardia associated with succinycholine administration in
RSI. The idea is that kids tolerate tachycardia very well but do
poorly with bradycardia. The dose of atropine for pretreatment
is 0.01 mg/kg IV (minimum dose is 0.1 mg).
 Although it continues to be recommended, randomized control
trials have shown no difference in the rate of bradycardia in
pediatric patients receiving succinycholine whether they got
atropine or not (McAuliffe, 1995). Most airway "gurus" have
dropped atropine as a recommendation for pretreatment but
suggest having it at the bedside in case bradycardia occurs.
Discuss the Utility of
Pretreatment Agents in RSI.
 Fentanyl: Fentanyl pretreatment is thought to attenuate the
sympathetic response to direct laryngoscopy. This sympathetic
response can drive up heart rate and blood pressure and so may be
detrimental to patients, especially those patients with ischemic
heart disease, aortic dissections etc.
 The dose required for full attenuation is 11 - 15 mcg/kg but this
large a dose may cause significant hypertension. Doses as low as 23 mcg/kg will produce some attenuation and are more reasonable
for RSI purposes.
 Important to note that the use of opioids in pretreatment for head
trauma is an area of controversy. The Walls text recommends it,
but be aware there is some evidence to suggest that it may increase
ICP in patients with head injury (de Nadal, 1998).
Discuss the Utility of
Pretreatment Agents in RSI.
 Lidocaine: Lidocaine pretreatment is also believed to
attenuate the response to direct laryngoscopy but instead of
sympathetic response the response is bronchoconstriction
and increased intracranial pressure.
 The evidence for this is incomplete at best, but many argue
there is little downside to a dose of lidocaine in this
situation. A 2001 literature review by Robinson and Clancy
found no evidence that pretreatment with lidocaine in
patients with head injury undergoing RSI improved
neurological outcomes.
 The dose for both reactive airway disease and increased ICP
is 1.5 mg/kg IV.
Web Page
 www.emlyceum.com
 Launched in August 2011
 Free, includes downloadable versions of the
posters, easy to print and use in your
department
Future Directions
 Involvement of non-Bellevue residents and
attendings in topic development
 Creation of blog/chat on a regular basis to
discuss/debate topics remotely
 Development of strategy to analyze impact of topics
on actual management
Acknowledgements
 Whitney Bryant, MD, MPH
 Audrey Wagner, MD
 Salil Bhandari, MD
 Meghan Spyres, MD
 Lewis Goldfrank, MD
The Website
www.emlyceum.com