ERCAST

By Hippo Education LLC.

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Description

current issues in emergency medicine, reviews, opinion and curbside consults

Episode Date
Internal Medicine in the Emergency Department
25:59

Internist Neda Freyha sprinkles some IM in the ED - how to interpret TSH levels and why aspirin is no longer recommended for a-fib thromboprophylaxis.

Jun 03, 2018
Massive GI Bleed on Anticoagulants
30:15

Rob and Tom Deloughery discuss management of actively bleeding patients who have been prescribed anticoagulation medications.

May 04, 2018
Mind of an Addict
22:45

Our guest today is Joe Polish. Unlike most guests on this show, Joe is not involved in medicine- heis one of the best known marketing minds on the planet. He is the creator of the Genius Network which is the place high level entrepreneurs go to get their next big breakthrough with access to connection, contribution, and collaboration. Joe is also a best selling author and renown podcaster with I Love Marketing, genius network, Rich Cleanerand 10x Talk. But none of those things are why Joe is on the show today. Joe is also an addict, but deeper than that, he’s turning his experience with addiction into a force for change with Genius Recovery and Artists for Addicts.

 

In this episode

  • Open Letter to Anyone Struggling with Addiction
  • Joe's  story of addiction and how he's dealt with it on the path to recovery
  • The roots of addiction, why punishing addicts doesn't work and what we can do instead
  • Sex addiction and connection 
  • The Craving Brain: Why addiction may not be a choice and what we need to understand about it
  • How to bring more compassion and empathy to addicts and help them recover
  • Gabor Mate:"Not why the addiction, but why the pain?"
  • Be transformational, not transactional

 

Apr 30, 2018
ZDoggMD
44:11

Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone.

 

ERcast 2.0 Launches May 1

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In this interview we cover a wide range of topics including

  • Underwear
  • How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist
  • Meditation
  • The Mind Illuminated
  • The roots of anxiety
  • Mental preparation before giving a talk
  • ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement
  • Nurse practitioners

 

A Smattering of Performance Improvement, Stress Management, and Wellness Episodes

 

Full Video Interview Below

 

https://www.youtube.com/watch?v=bujZmXEtuHA

 

My Favorite Zdogg Song

https://www.youtube.com/watch?v=NAlnRHicgWs

 

Apr 24, 2018
C Diff Treatment Changes
12:12

A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.

 

Mentioned in this episode

 

 

New IDSA C Diff Guideline Treatment Recommendations

 

Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5)

First Line

  • Vancomycin 125 mg PO QID for 10 days
  • Fidaxomicin 200mg PO  BID for 10 days

Second line

  • Metronidazole 500mg TID PO for 10 days

 

Initial Episode, Severe (WBC >15k, creatinine >1.5)

  • Vancomycin 125 mg PO QID for 10 days
  • Fidaxomicin 200mg PO  BID for 10 days

 

Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon)

  • Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube.
  • If ileus, consider adding rectal instillation of vancomycin.
  • Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present

 

First Recurrence

• Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR

• Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR

•  Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode

 

 

Photo Credit Photo by Gabor Monori on Unsplash

 

 

The Guidelines

  • McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280

Original Studies

  • Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597
  • Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937
  • New Evidence Favoring Vancomycin
  • Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306
  • Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326

CDC C. Diff Statistics

 

New York Times article on the association of the rise of new sweeteners and the rise of C. diff.

The Germs That Love Diet Soda

Apr 17, 2018
Pseudoseizures (PNES)
15:31

Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.

 

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Are patients with PNES ‘faking it’?

  • PNES is a conversion disorder: an unconscious manifestation of psychological trauma.
  • Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
  • PNES is not ‘faking it’ or lying

 

Challenges

  • Patients with PNES may also have true epileptic seizures
  • Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out

 

How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it?

PNES

  • Seizures related to a specific stimulus (sound foods, body movement)
  • Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
  • Maintenance of consciousness and may have some of the below
    • may guard the face with passive hand drop
    • resist eyelid opening
    • visual fixation on a mirror
    • Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES.  If they grimace, probably not an epileptic seizure.

Faking Seizures

  • Talking
  • Purposeful movement
  • Avoids injury
  • May use convulsions as a way of harming staff
  • Intermittently awake and vocal during the episode

Epileptic seizure

  • Convulsive frequency decreases, amplitude increases as seizure progresses
  • No response to pain
  • Allow passive eye opening

 

A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.

  • Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
  • Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
  • Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
  • Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
  • Urinary incontinence, more common in epilepsy, but does happen in PNES.
  • Post-ictal recovery period. Surely, this is the sine qua non of epilepsy.  It is way way more common following generalized epileptic seizures but happens in around 15% of PNES.
  • The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES

 

Walker’s take home points

  • PNES patients aren’t ‘faking it’
  • This is a real disorder, it's just not epilepsy

References

Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733

Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136 

Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand. "Presenting the diagnosis of pseudoseizure." Neurology 40.5 (1990): 756-756. Full Text PMID:2330101

Mar 21, 2018
What Canada Can Teach Us About CAT Scans
22:25

Joe Habbousche is the CEO of MDCalc, the world's most used online medical calculator. Chances are, you've used it yourself. Joe is a passionate advocate for the practice of evidence based medicine and the proper use of clinical decision tools. In this episode, we dissect one of his favorites: the Canadian CT Head Injury/Trauma Rule

 

Canadian CT Head Injury Rule

  • Derived and validated in a large patient population
  • Overall 8% of patients had positive CTs, but only 1.5% required intervention

 

Two sets of criteria

High Risk/Major Criteria

  • Designed to capture patients that went on to require intervention.

Medium Risk/Minor Criteria

  • Added on to the high risk criteria to capture those with clinically important brain injury- CT findings that require admission or observation

 

Who does this not apply to?

  • Patients on blood thinners/bleeding disorder
  • Under 16 years old
  • Seizure after trauma
  • No clear history of trauma
  • Obvious penetrating skull injury or obvious depressed fracture
  • Acute focal neurological deficit
  • Unstable vital signs associated with major trauma
  • Returned for reassessment of the same head injury

This is a one directional rule

  • Designed to be sensitive but not necessarily specific
  • This decision rule was designed because when CT imaging is done in all comers with head injury, it has very low yield
  • The CT Head Injury/Trauma rule asks, "Can I carve out a cohort of patients who we know will not have a need for this test."
  • If you fall in this group (the cohort that the rule says doesn't need the test), then you don't need the test
  • Here's the one directional part: If you fall outside that group, the group the rule says does not need the test....the rule DOES NOT COMMENT. It is not studying anyone outside the group that has been deemed safe to not have the test done

 

Canadian CT Head Rule

Applies to this group of patients

  • Blunt trauma to the head resulting in witnessed loss of consciousness
  • Definite amnesia or witnessed disorientation
  • Initial emergency department  GCS score of 13 or greater as determined by the treating physician
  • Injury within the past 24 h

 

High Risk Criteria: Rules out need for neurosurgical intervention

Fails rule with any of the following

  • GCS <15 at 2 hours post-injury
  • Suspected open or depressed skull fracture
  • Any sign of basilar skull fracture? Hemotympanum, raccoon eyes, Battle’s Sign, CSF otorrhea/rhinorrhea
  • ≥ 2 episodes of vomiting
  • Age ≥ 65
 
Medium Risk Criteria: In addition to above, rules out “clinically important” brain injury (positive CT's that normally require admission)

Fails rule with any of the following

  • Retrograde amnesia to the event ≥ 30 minutes
  • “Dangerous” mechanism: Pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from > 3 feet or > 5 stairs.

 

If all criteria are met/the patient does not fail the rule, the Canadian Head CT Rule suggests a head CT is not necessary for this patient (sensitivity 83-100% for all intracranial traumatic findings, sensitivity 100% for findings requiring neurosurgical intervention). The confidence intervals for these sensitivities range from low 90's so 100%. Since it's unlikely the test is actually 100% sensitive, I'd say it's 'close to' 100% sensitive.

 

 

Papers mentioned in this podcast

Original CT Head Rule Study

Stiell, Ian G., et al. "The Canadian CT Head Rule for patients with minor head injury." The Lancet 357.9266 (2001): 1391-1396.PMID: 11356436

Validation Study

Stiell, Ian G., et al. "Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury." Jama 294.12 (2005): 1511-1518PMID: 16189364

 

 

Mar 12, 2018
Winter 2018 Journal Club
43:39

In the edition of the Ercast journal club

  • thrombectomy in pts with delayed stroke presentation shows promise
  • beware behavioral changes after procedural sedation
  • kids with isolated linear skull fractures have a good short term prognosis
  • procalcitonin may help decrease abx use in respiratory infections
  • steroids in mild sore throat help... a little

 

Registration for ConCert (the big board recertification exam we take once a decade) has opened. If this is your year to take the exam, there's only one place to go for board review.

 

The DAWN Trial

  • Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2017). PMID:29129157
  • What happens when thrombectomy is done when last normal was over 6 hours ago?
  • 206 patients with occlusion of the intracranial internal carotid artery, middle cerebral artery, or both
  • these were patients excluded from TPA because of time from onset or they had persistent occlusion despite TPA
  • Pts had to get either perfusion CT or diffusion weighted MRI to see if there was salvageable brain (there had to be)
  • 107 got thrombectomy and 99 didn't.
  • 90 day functional independence: 49% thombectomy vs 13 % controls
  • No significant difference in symptomatic intracranial hemorrhage or 90 day mortality
  • Trial stopped early because of superiority of thrombectomy
  • Majority of patients were wake up strokes, a group we've had pretty much nothing to offer previously
  • Industry sponsored, many conflicts of interest

 

  • Rob's take-This trial uses salvageable brain as a determinant of treatment which makes sense as these are the patents who may actually benefit from reperfusion. This purports to speak for the patient 6-24 hours, but from what I can tell, treatment was heavily skewed toward those with time from last normal 16 hours and under, so it doesn't really tell us much about 24 hours. I will be consulting stroke centers with this patient cohort.
  • Adam's take- Impressive. I like that this is tissue based, not time based.

 

 

Skull Fractures in Kids

  • Bressan, Silvia, et al. "A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children." Annals of emergency medicine (2017). PMID: 29174834 
  • Are pediatric patients with isolated skull fractures at increased risk for short term adverse events?
  • Pool of 21 studies, over 6,000 kids with isolated skull fractures.
  • One required emergency neurosurgery, none died.
  • All kids had CT scan or MRI to exclude intracranial injury
  • 6 out of 570 had bleeding on a second scan and zero had surgery. The incidence of delayed hemorrhage is super low and even those with bleeding didn't need an intervention. Unless there is a change, you don't need to rescan.

 

  • Author take home: "Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns."
  • Rob's take-An otherwise well appearing child with isolated skull fracture has an excellent short term neurosurgical prognosis and probably don't need hospitalization based on the skull fracture alone
  • Adam's take-Open and shut case. One kid out of over 6,000 is pretty good odds and that one patient got meningeal repair.

 

 

Procalcitonin is dead. Long live procalcitonin

  • Schuetz, Philipp, et al. "Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis." The Lancet Infectious Diseases 18.1 (2018): 95-107. PMID: 29037960
  • Over 6,000 patients with respiratory infections
  • Decision to give antibiotics based on procalcitioin level
  • Primary endpoints: Mortality, treatment failure
  • Secondary endpoints: Antibiotic use
  • No significant difference in death, treatment failure, ICU length of stay
  • Antitiocis initiated 86% controls, 70% procalcitonin guided and  shorter duration of abx using procalcitonin as the guide
  • Fewer Abx side effects with procalcitonin guided therapy

 

  • Adam's take-This is not a lifesaving study, this is a safety study. The point is, can you safely withhold antibiotics from people? This study says you can, based on procalc level in a patient with respiratory infection. The scenario I envision is someone with CHF, COPD, fever, and coughing. If the procalc is low, I don't have to add a horrendous quinolone to your 25 other meds, you can take tessalon perles and do better. I'm going to keep one more abx prescription out of the pool and it's not going to harm the patient. This is a noniferiory trial to me. Prescribing fewer antibiotics is a worthwhile goal to me. We know that using procalcitonin for that purpose works and this study says it is safe.

 

Steroids for sore throat

  • Little, Paul, et al. "Effect of oral Dexamethasone without immediate antibiotics vs placebo on acute sore throats in adults: a randomized clinical trial." JAMA 317.15 (2017): 1535-1543. PMID: 28418482
  • RCT of 576 adults with sore throat not requiring immediate abx. Treated with either steroid or placebo
  • Most afebrile and did not have pus on tonsils
  • Results: Symptoms better at 48 hours (but not 24) with dexamethasone

 

  • Rob's take- Set the expecation that it will take 48 hours to start feeling better if giving steroids. That being said,  I don't think that steroids are worth it in most mild sore throat patients. NSAIDS, tea, and time
  • Adam's take- A cofounder for me was that 14% of the dexamethasone and 19% of no dex group had strep, a confounder I don't like. Steroids probably work a little, they're probably safe, but they're not amazing

 

The Brain Does Not Love Ketamine as Much as You Do

  • Pearce, Jean I., et al. "Behavioral Changes in Children After Emergency Department Procedural Sedation." Academic Emergency Medicine (2017). PMID: 28992364 
  • 82 kids received ketamine for procedures in the ED
  • Most had forearm fracutres
  • Most had analgesia before procedure
  • 22% with negative behaviors changes after discharge. Anxiety, aggression, withdrawal, sleep anxiety, separation anxiety
  • Higher odd of this happening in kids anxious before procedure, nonwhite

 

  • Rob's take- ketamine is an excellent drug, but can have lasting effects. Also, it's not totally benign, one patient had over 30 seconds of apnea. Still one of our best options, but discuss with parents the post discharge behavioral changes that might occur
  • Adam's take- I don't think this is a study about ketamine at all. This says nothing about ketamine, this talks about procedural sedation. There is a long history of research about general anesthesia that shows a similar pattern- post op kids have behoaboiral disturbance a week after and the kids who come into the OR have worse outcomes, and if you treat the anxiety before the procedure, they have better outcomes.This could have been propofol nitrous, whatever. The kids who start out anxious pre-procduere have a much higher incidence of behavioral disturbance post procedure.In my opinion, this study shows that anxious kids are more likely to be disrupted by this experience than non-anxious kids. I am going to give a lot more versed. Maybe this is the versed indication that works with ketamine.
Mar 05, 2018
Why Doctors Get Sued for Missed MI
28:57

Amal Mattu gives his thoughts on why we actually get sued for missed MI. Is it the patient who has an impeccable workup with shared decision making? Or are there other factors/patient characteristics that commonly show up in lawsuits? 

In part 2, we talk with Mike Weinstock about criticism of his paper How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? 

 

Episode contents

Frontmatter

 

Part one. Amal Mattu on lawsuits for missed myocardial infarction

  • Do we mitigate medico-legal risk if we use a validated decision instrument or pathway? Amal feels that we do. You are applying validated literature to your practice.
  • Problems arise when the score, HEART for example, is miscalculated or guessed at. If you're going to use a protocol or score, be sure you're using it correctly
  • What are the things that Amal sees as common factors that lead to 'missed MI' lawsuits?
    • Misread EKGs
    • Young women presenting with atypical symptoms (atypical chest pain, shortness of breath, fatigue)
    • Young patients
    • Upper abdominal pain, especially without abdominal tenderness
    • Diagnosing a patent with 'reflux' when the patient was actually having an acute coronary syndrome. Inferior MIs in particular may masquerade as reflux symptoms or the patient with ischemia may have concomitant (true) reflux.
  • In 2015, Amal discussed his pathway for evaluating ED chest pain patients. Here is the protocol

Part two. Mike Weinstock on risk of CRACE (Clinically Relevant Adverse Cardiac Event), criticism of How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? 

  • Original Episode air date October 30, 2017
  • We think we protect patients by admitting them to the hospital, but looking at the numbers, that might not be the case. The criticism of Mike’s paper that teased out the risk of CRACE in patients with non-ischemic interpretable EKGs and negative troponins, was that all patients were evaluated in the hospital. Did hospitalization confer some unmeasured benefit? Can we extrapolate that risk of CRACE in patients who have been hospitalized applies to discharged patients with the same profile? This is an ongoing debate, but the data is some of the best we have and can still inform discussions with patients.
  • We don't sent patients home and tell them they have no disease, we send them home with a plan for continued evaluation.

How does Mike use this information?

  • If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available.
  • He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk.
  • The Weinstock Credo: Don’t practice defensive medicine. Document “defensibly”

 

References

Singh, Swarnjit, et al. "The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease." Annals of internal medicine 117.10 (1992): 824-830. PMID: 1416557

Dobrzycki, Slawomir, et al. "Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?." International journal of cardiology 104.1 (2005): 67-72. PMID: 16137512

Pope, J. Hector, et al. "Missed diagnoses of acute cardiac ischemia in the emergency department." New England Journal of Medicine 342.16 (2000): 1163-1170. PMID: 10770981

Feb 26, 2018
Haloperidol for Analgesia
25:43

One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.

  

Episode Guide

In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17).

Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain.

A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects.

Haloperidol is an analgesic option for patients taking chronic opioids.

Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV,  5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose.  If that doesn’t work, he uses analgesic dose ketamine.

For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum.

Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses.  Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check.

Check out Reuben's blog Emergency Medicine Updates and follow him on Twitter

 

References

Opioid Hyperalgesia

  • Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text linkPMID: 21412369 
  • Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link.  PMID: 21029354

Droperidol for analgesia

  • Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396.  PMID: 20832967
  • Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279
  • Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073

Early studies on Haloperidol for analgesia

  • Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741
  • Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10.
  • Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130.

Haloperidol for pain

  • Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669
  • Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode
  • Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990
  • Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034
Feb 18, 2018
When Consultants Give Bad Advice
35:13

Sam Ashoo is an ED doc practicing in Tallahassee, Florida. He has been an ED director, coding and billing chief medical officer, international educator, and runs the Admin EM blog. That blog name might sound nerdy (and it is) but his short write ups on common clinical problems are famously high yield.

In this episode, Sam gives his strategies on what to do when the consultant on the other end of the phone call is giving questionable advice.

Before jumping in to the episode, take a few minutes for the ERCast listener survey.The survey lets me know who you are, what you do, and what you need when it comes to medical education. Thanks in advance.

 

Discussion topics

  • Are you disagreeing with your consultant or is the information you are being given simply wrong?
  • Why determining the root cause of the bad advice can help lead to resolution of conflict
  • Should you apologize for bothering a consultant when you call them?
  • What to do when a consultant is dismissive of your concerns about a patient
  • Factors that may lead to questionable advice from a consultant
  • Bad advice is usually not malicious (even though it may feel that way)
  • Be aware of downstream effects of negative interactions with consultants

 

Bonus Content

  • What follows is a summary of a conversation with Dr. Jim Adams, Chairman Northwestern University Emergency Medicine. He is a master of conflict management, resolution, and prevention

How to insulate ourselves from the stress of conflict with consultants

  • Get to know them personally. Build social capital and friendships. We underestimate the power of social connection to prevent negative interactions.
  • Slow down before you make the call and think about why you're calling. Know your needs and know your ask. (example of rambling vs focused).
  • Don't give your consultant an order, call with a specific need.
  • Speak at a measured pace. While you may think you sound calm and friendly, it's possible that what's heard on the other end of the line is pressured, pushing, and curt. Trainees and new attendings are especially vulnerable to this. It's not a mystery why this happens-your work environment is the perfect setup for the opposite of a calm phone presence. At baseline, the ED is high pressure and there are myriad demands for your time and attention. When you sound pressured, the person on the other end of the call feels pressured, then they match your tone... and then YOU think that THEY are the problem!
  • Consider reciprocity when dealing with an irritated consultant. If you're irritated, they're irritated. It's infectious. If you choose to be happy and express appreciation for the consultants advice or coming in, that changes the dynamic. If you lead with irritation when they come into the ED to evaluate a patient, what do you think is going to happen 9 times out of 10? Your consultant will be more irritated!
  • When you get a hard time on the phone, your brainstem screams "threat, aggression!" You start to get angry and want out of the conversation. That is a primitive conversation. Your emotion is now driving you. Take some reset breaths, try combat breathing, recognize and be in control of the emotional response
  • At the end of the conversation, show appreciation for the consultant's expertise. If it's a surgeon, Jim says, "It looks like this patient needs your hands." If it's an internist, he might say, "It looks like this patient needs your time and wisdom." That may sound lame/dorky/fake/etc but you are doing two things: expressing gratitude and making them feel needed. Feeling needed is irresistible for doctors (or pretty much any human) - it makes them feel good about their jobs. Even if they're tired and cranky, making someone feel needed and valued leads to better interpersonal results.
  • In any conflict, there is a moment when you should stop listening to what they're saying and focus instead on why they're saying it. Often a consultant that is giving you a hard time or is dismissive may not be in  position to help you at this moment (they might busy, tired). you may also have a consultant who acts like a bully and tries to dominate you in a conversation. They may in fact just be a bully, but sometimes it's a case that where they have nothing to offer the patient. When a person is not giving you answers that are not acceptable, find the things that you'd agree on that are acceptable.
  • When there is a negative interaction, let your department chair know. On investigation, what's often uncovered is burnout, depression, substance abuse, going through a divorce, etc. Of course, some people have grown accustomed to exhibiting rude behavior and it has nothing to do with other life circumstances.

 

The Case

  • You are seeing a patient with a VP shunt who is having repeated seizures. They are followed by a neurosurgeon for all of their neurologic related needs (the family called the neurosurgeon who recommended they come see you). After a workup in the emergency department, it's still not clear why the patient is having seizures.
  • You call the neurosurgeon and the response is something like this, "Why are you calling me? This patient doesn't need surgery. Do you understand what I do? I am a neurosurgeon, that means I do brain surgery. This patient doesn't need that."

  • You reply, "I understand that, but you recommended the patient come to the ED, they are your patient and have complex brain hardware so I thought you'd like to know what's going on and we could discuss treatment options."

  • "I'm not sure why you can't understand what a neurosurgeon does. Are you a doctor..."

  • If the consultant has a truly pathologic personality, there's no magic fix or workaround. Just don't take their derision toward you personally. You'll find that they are exhibiting the same behavior in every part of their life.
  • There are other paths you can take besides wanting to smash the phone into the desk in a fit of rage. Your primitive brain is exploding right now, begging to go full caveman here. Take a breath, stay calm and measured and use the technique of BLEND and REDIRECT
  • Blend - restate what you do agree on and Redirect- see if you can align with them to help the patient.
  • Blend "I think we can agree this is a really complex patient. There's nothing suggesting they need acute surgery."  Redirect "But they're having this problem and I need some guidance on how to best help this patient and family." You are blending with what they're saying and redirecting them toward your need and seeing if they can help provide a solution.

 

The solid

Before you go, take a moment for the ERCast listener survey.

It's short, sweet, and full of info that will help me help you. And since you've gotten this far on the blog, I'll also tell you that there's a $50 Amazon gift card up for grabs.

Feb 11, 2018
Anorexia Nervosa may not scare you but it should
32:58

Vicky Vella is an emergency physician practicing in the United Kingdom with a special interest and expertise in eating disorders. In December of last year, Vicky had a guest post on the St Emlyn’s blog about the MARSIPAN Guidelines. Never heard of them? Neither had pretty much anybody. MARSIPAN is an acronym for Management of Really Sick Patients with Anorexia Nervosa.

Anorexia is often viewed as a chronic condition that doesn't really warrant emergency care, but that's not the case. Mortality with anorexia nervosa is high (on the order of 10-20%) and patients can present, as MARSIPAN suggests, really sick.

 

Consider an eating disorder/anorexia in patients presenting with

  • Self Harm. Up to 70% of patients with anorexia will self harm
  • Diabetic Ketoacidosis.  In the UK around half of 15-25 year olds with type 1 diabetes will withhold insulin to try and lose weight. Not all of them will have an eating disorder, but many will
  • Vasovagal syncope. We often ask if a patient had breakfast or enough to drink today, but there may be an underlying eating disorder

 

What question(s) to ask

  • Vicky starts with, "What's your relationship with food?" "Do you eat regular meals?"
  • The patient may not disclose that there's a problem. Information may come from a family member

 

Who has anorexia nervosa

  • Highest risk is 13-17 yo age group, both male and female
  • Can actually affect all ages, races, genders

 

What's the difference between anorexia nervosa and someone who just doesn't eat much?

  • Anorexia is a mental illness. Sometjing the person doesn't have much control over
  • Less of a desire to be thin than a fear of being obese
  • Guilt associated with eating
  • May restrict intake, exercise to burn off consumed calories
  • Often mood swings, social isolation, can become aggressive toward family

DSM 5 Criteria

  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
  2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
  3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

 

Red Flags in the Anorexia Workup (from the MARSIPAN Guidelines)

BMI

  • low risk 15–17.5
  • medium risk 13–15
  • high risk <13

Physical examination

  • low pulse (<40bpm)
  • blood pressure (especially if associated with postural symptoms)
  • core temperature (<35C)
  • muscle power reduced
  • Sit up–Squat–Stand (SUSS) test (scores of 2 or less, especially if scores falling)

Blood tests

  • low sodium: suspect water loading (<130 mmol/L high risk) or occult chest infection with associated SIADH
  • low potassium: vomiting or laxative abuse (<3.0mmol/L high risk) (note: low sodium and potassium can occur in malnutrition with or without water loading or purging)
  • raised transaminases
  • hypoglycaemia: blood glucose <3mmol/L (if present, suspect occult infection, especially with low albumin or raised C-reactive protein)
  • raised urea or creatinine: the presence of any degree of renal impairment vastly increases the risks of electrolyte disturbances during re-feeding and rehydration (although both are difficult to interpret when protein intake is negligible and muscle mass low)

ECG

  • bradycardia
  • raised QTc (>450ms)
  • non-specific T-wave changes
  • hypokalaemic changes

 

Bibliography

MARSIPAN Guidelines PDF Link

Junior MARSIPAN Guidelines PDF Link

Arcelus, Jon, et al. "Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies." Archives of general psychiatry 68.7 (2011): 724-731. Full Text  PMID: 21727255

What psychiatric disorder has the highest mortality? Article Link

 

 

Feb 05, 2018
Cellulitis
17:06

Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?

 

The great cellulitis mimic: Stasis Dermatitis

  • Similar in appearance to cellulitis
  • Often bilateral (where cellulitis is usually unilateral)
  • Risk factors include venous stasis, lymphedema
  • Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation

Treatment

  • Many recommendations out there, many of them consensus, opinion or based on weak data
  • Elevation
  • Compression if the patient can tolerate it
  • Wet dressings if there is crusting and exudative eczema
  • Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
  • If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)

 

Admit or go home?

  • Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
  • No validated decision instruments regarding admission or discharge
  • 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis  found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
  • Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
  • Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
  • A nice review of the admit or discharge cellulitis question can be found here

 

Single or double antibiotic coverage

Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235

  • 500 patients with cellulitis
  • Treated cephalexin alone or cephalexin plus TMP/Sulfa
  • No significant difference in outcome

Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080

  • 150 patients with cellulitis
  • Treated cephalexin alone or cephalexin plus TMP/Sulfa
  • No significant difference in outcome

Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin

 

Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation.

 

References

  • Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
  • Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
  • Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
  • Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
  • Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
  • Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
  • Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
  • Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
  • Original Kings of County Analysis of Admit or Discharge Cellulitis
Jan 29, 2018
Performance Coach Jason Brooks
01:06:07

Jason Brooks PhD is a performance coach helping health care providers, athletes, and other high level performers live better, work better, and be better. In this episode Jason gives his strategies and tactics on myriad topics including: three techniques for stress inoculation, improving test taking, the unseen costs of hiding ignorance, and what habits are common among high level performers.

 

Episode Contents

  • A look back at ERCast episode one on Rectal Foreign Bodies
  • Jason's work with physicians through Phenomenal Docs
  • You can't stop the waves but you can learn to surf - Jon Kabat Zinn
  • Who consults a performance coach? Those who are stuck and want to become unstuck. Those who are excelling and want to excel at an even higher level. These forces can exist simultaneously in the same person
  • What's easier to accomplish? Moving from a perception of low-level performance or getting to a higher level of excellence?
  • Answering the question, "Why is this happening to me?"
  • Start with Why by Simon Sinek Book TED Talk
  • Having an internal yardstick to gauge how decisions align with your values
  • Making time for periodic reflection
  • The importance of adversity
  • It's not what we do that causes burnout, it's losing sight of why we do it
  • Common habits of top performers that transcend a particular career
  • Humility is a common attribute in high level and respected performers driven to be the best I can be, but I don't have all the answers
  • Expectations of a master physician to learners: make me better by contributing to my knowledge base, and I expect you let me know if you think I'm making a mistake
  • Shedding the fear of exposing ignorance. What is the real cost of not exposing ignorance? Leaving knowledge on the table
  • Three techniques for stress inoculation
  • Practice through visualization
  • Breathing techniques to trigger parasympathetic response and mitigate sympathetic fight/flight/flee
  • Using a trigger word to de-escalate stress (mine is "level down")
  • Improving test taking performance
  • How an Olympic archer recalibrates after missing a shot
  • Connect with Jason: Facebook, Twitter, email doctorjbro at gmail dot com

 

 

Jan 22, 2018
Should I give bicarbonate in DKA?
19:50

Should I give bicarbonate to DKA patients with severe acidemia? I've certainly been admonished for NOT doing it. The reason for withholding bicarb has been that I've heard that it doesn't help and may actually be a bad idea. I can't say the action (or inaction) was based on a deep understanding.

How could bicarb in DKA be a bad idea if even the American Diabetes Association (ADA) recommends we give a bicarb to DKA patients with pH under 6.9? The argument in favor of giving bicarb is that the more acidemic the patient, the higher the risk of circulatory collapse and cardiac arrest. Even though there is no evidence of benefit, the ADA gives a very specific set of steps to take in the low pH patient..

  • Because severe acidosis may lead to numerous adverse vascular effects, it is recommended that adult patients with a pH less than 6.9 should receive bicarbonate. Specially 100 mmol sodium bicarbonate, two ampules, in 400 mL sterile water with 20 mEq KCL admitted at a rate of 200ml/hr for 2 hours until the venous pH is over 7. If the ph isn’t over 7 at that point, they say repeat the bicarb infusion every 2 hours until the ph is over 7.0

With that sort of exact guidance, you'd think there would be evidence to back it up, but here is the sentence that precedes the above recommendation.

  • No prospective randomized studies concerning the use of bicarbonate in DKA with pH values <6.9 have been reported.

Because of the lack of evidence, the UK guidelines say this

  • Adequate fluid and insulin therapy will resolve the acidosis in diabetic ketoacidosis and the use of bicarbonate is not indicated 

But as the saying goes, "absence of evidence is not evidence of absence", so is there a downside to giving bicarb to DKA patients? It turns out there there may be. Several FOAMed bloggers have tackled this in great detail: Pulm Crit, REBEL EM, Life in the Fast Lane, emdocs, and Jacobi EM. (just to name a few)

 

Here are just of few of the problems with bicarb in DKA patients

 

Giving bicarb drives potassium into the intracellular space.

  • DKA patients are total body potassium depleted.
  • Once the IV fluid and insulin get going the potassium is likely to drop quickly. In a patient already at risk for hypokalemia, administration of bicarb can drop the serum potassium even faster.

Does bicarbonate infusion in DKA improve outcome?

  • The preponderance of evidence, albeit small numbers of patients, suggests that bicarb does not improve outcome, even in those with low pH.
  • The most widely cited article on this is a 2011 systematic review from  Annals of Intensive Care that found no evidence of benefit for either neurologic or hemodynamic outcome. There was some evidence of a transient improvement in acidosis with the first 2 hours but no evidence of clinical efficacy.

Bicarb slows ketone clearance.

  •  A 1996 study found that giving bicarb slowed the clearance of ketones and AND  transiently increased acetoacetate and beta hydroxybutyrate levels. 

Bicarb may cause CSF acidosis. This goes back to a 1967 study by Posner and Plum.

  • A series of 7 severely acidotic patients.
  • Some were obtunded and some weren't 
  • The authors postulated that it’s the degree of CSF acidosis that determines coma more than peripheral acidosis.
  • To study this, whenever blood ph was studied, they did a neurologic exam and a lumbar puncture.
  • Lower CSF pH correlated with a lower level of consciousness.
  • In 2 patients with DKA, they found that giving IV bicarbonate infusion, while it improved serum pH, was associated with more acidotic CSF.
  • Other studies have called the importance or even validity of bicarb infusion causing CSF acidosis into question and found treating DKA how we regularly do can itself cause the CSF pH to transiently drop.

George Willis, ED doc and DKA expert, uses bicarb in DKA in three scenarios

  • DKA with cardiac arrest
  • Persistent hypotension despite vasopressors
  • Hyperkalemia with arrhythmia

So should ANY DKA patients get bicarbonate? I think there are several choices

  • You can follow the US/ADA guidelines and use bicarb if the pH is under 6.9. This is not based on solid evidence, more-so the worry that severe acidemia can lead to circulatory collapse (and bicarb may mitigate that)
  • You can follow the UK guidelines and just not give bicarb at all
  • I like the Willis rule of 3. Hyper K with arrhythmia, severe hypotension despite pressors, cardiac arrest -because these are patients who are about to die. With hypo-K, you might push just enough potassium into the cells to make a difference. In cardiac arrest, you might give a quick bump up in pH to improve the cardiovascular situation, then again, you might not.

Mentioned in the intro

 

References

Kitabchi, Abbas E., et al. "Hyperglycemic crises in adult patients with diabetes." Diabetes care 32.7 (2009): 1335-1343.

Dyer, P. H., and M. S. Hamersley. "Diabetes UK Position Statements and Care Recommendations Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis." (2011).

Chua, Horng Ruey, Antoine Schneider, and Rinaldo Bellomo. "Bicarbonate in diabetic ketoacidosis-a systematic review." Annals of intensive care 1.1 (2011): 23.

Savage, M. W., et al. "Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis." Diabetic Medicine 28.5 (2011): 508-515.

Okuda, Y. U. K. I. C. H. I., et al. "Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis." The Journal of Clinical Endocrinology & Metabolism 81.1 (1996): 314-320.

Posner, Jerome B., and Fred Plum. "Spinal-fluid pH and neurologic symptoms in systemic acidosis." New England Journal of Medicine 277.12 (1967): 605-613.

 

Jan 15, 2018
The White Coat Investor
01:02:17

The White Coat Investor (AKA Jim Dahle, MD) talks debt, investing, philanthropy, investment philosophy, and investment strategies for different stages of your career.

 

Key Links from this episode

 

When Jim was an intern, he didn't know much about finance. His education started with this book

 

Books Jim recommends as foundational reading to understand personal finance

 

White Coat Investor advice for a medical student

  • Try to spend as little as possible. Every dollar you spend in medical school is going to be 3 dollars you pay back later
  • This is they time you're expected to be poor. Be frugal
  • Your specialty choice has a huge effect on your future financial life. Pick the one you will be able to work at the longest that makes you the happiest.

 

Advice to a young doctor

  • The year that matters most in your financial life is your first year as an attending physician. That year sets habits.
  • In med school and residency, have a plan in place for your first 12 attending paychecks.
  • In the first few years after residency, live the lifestyle of a resident while earning like an attending. This can lead to rapid savings and loan repayment
  • Embrace the habit of saving
  • Calculate your annual savings rate/what you're putting toward retirement. Amount of annual savings divided by gross income. That number should be around 20%
  • Look at your purchases from the point of view, "Will this make me happy?" The is the essence of budgeting: attaching your values to how you spend your money
  • Each month, review where your money is going. Is that where you want it to be going? If it's not, make some changes.
  • Don't buy on credit. Spending your money on payments is not what you want to be doing

 

Financial Advisors

  • Most doctors want or need a good financial advisor
  • The problem is that what we want is just to have a 'money guy' that takes care of all the money and we don't have to pay attention to it
  • To make sure you're getting good advice at a fair price, you'll need at least a basic level of financial education (or at least get a second opinion)
  • Be aware of the fees your advisor is charging. Expect at least 4 figure amounts

 

Starting residency. Buy or rent?

  • Buy a home when you are in a stable professional and social situation
  • there are high transit costs. It costs about 15% of the value of the home to make the 'round trip in and out of the home.About 5% to get in and 10 % to get out. If you're not there long enough for the home's appreciation to make up for that 15% loss, you're probably going to come out behind
  • Homes appreciate about 3% per year
  • If you're in a 3 year recency, changes are you won't break even
  • White Coat Investor recommends most residents NOT buy a home and rent

 

New Attending. Buy or rent?

  • There is a good chance you will change jobs in the first few years
  • This is not the most stable professional time
  • Make sure the job work for you before you buy a house
  • Rent for the first 6-12 months
  • You should still be living like a resident during this first  year
  • Buy a home when you are in a stable professional and social situation

 

The "Point of Enough"

  • If you don't define it, it will always seem like a number that's twice what you have
  • Take how much you spend in a year and multiply it by 25. When you have that in assets, you have reached finically independence.

 

Real estate investing

  • Owning actual property is to the only way to do it. Other options include.....
  • The easiest way is the REIT. Real Estate Investment Trust index fund.
  • Syndicated real estate

 

Pay Down Debt vs Invest in the Market

  • Doing either one will increase your net worth (unless the market tanks)
  • Focus on what percentage of your income is going toward building wealth rather than what compartment that wealth building is going into
  • Student loans have a few negative aspects: You can't deduct the interest when you're an attending; student loans tend to have high interest rates. Try to get rid of student loan debt within 2-5 years after residency

 

Jim's Ideas on Giving/Philanthropy

  • Good for the soul
  • Develops a stewardship mentality
  • Giving money away sends a message to the subconscious that you have enough - you can give some away and still be OK
  • It keeps you connected to the rest of the world
  • It can make your portfolio more tax efficient

 

Dec 12, 2017
Finding the Joy
26:13

What gives you fulfillment in your job? If you know it, do you make purposeful choices to keep pointed in that direction?

 

Dec 08, 2017
Finding the Joy

What gives you fulfillment in your job? If you know it, do you make purposeful choices to keep pointed in that direction?

 

Dec 08, 2017
How to master CPR
41:27

Little things can make a big difference when it comes to running a code. EMS director and CPR aficionado Bill Reed gives a primer on High Performance CPR.

 

High Performance CPR core principles

  • Rate = 110 (100-120).
  • Metronome set at 110.
  • Depth = 2.0-2.5 inches.
  • Full recoil (no leaning).
  • Focus on rate & depth.
  • Listen for 15 second countdown warning of upcoming compressor switch.
  • Change compressors at 2-minute intervals/cycles.
  • Whenever possible, compressions performed from patient’s right side and new compressor comes in from the previous compressors right side.  Opposite is true for left sided compressions.
  • New compressor to “hover” over chest during rhythm check and/or defibrillation.
  • No more than 5 second pauses for compressor change or rhythm checks.
  • Immediately resume CPR after defibrillation (no pulse checks) or when rhythm check is complete.

Airway/Respiratory

  • NRB or nasal cannula at max flow initially.
  • BVM when available.
  • Rate = 1 breath every 10 compressions (unsynchronized).
  • Volume = no more than ½ ambu bag.
  • ETI when feasible or if no ROSC by 6-8 minutes as resources allow.
  • ETCO2 monitor connected as soon as feasible.
  • ETI should be accomplished by a provider other than code lead.
  • Hands off patient and/or airway device at 2-minute check.

 Monitor/Defibrillator

  • Attach as soon as possible.
  • Standard pad placement.
  • If witnessed VF while pads were in place for another reason, immediate charge and defibrillate.  Otherwise, ensure CPR for at least 30 seconds before delivering any defibrillations.
  • Pre-charge defibrillator 15 seconds prior to 2-minute checks.
  • If non-shockable rhythm at 2-minute check, “dump” charge by pressing the decrease energy selection button.
  • If shockable rhythm at 2-minute check, immediately defibrillate & resume CPR (no pulse checks).
  • If VF on rhythm check at 6 minutes (third cycle), immediately defibrillate, then roll patient 30 degrees towards new compressor, attach new posterior pad slightly below and medial to the patients left scapula, roll patient back and resume CPR.  Attach new anterior pad over left superior chest.  Connect new AP pads to new monitor/defibrillator.
  • At 8 and 10-minute checks (fourth & fifth cycles), pre-charge and defibrillate with new AP pads & monitor/defibrillator set at max joules.
  • At 12-minute check (sixth cycle), pre-charge both defibrillators to max joules and defibrillate both “simultaneously” if patient is still in VF.  One operator, two fingers.
  • Caveats
    • Changing to AP pads and/or double sequential defibrillation (DSD) is only for refractory VF.
    • If VF converts with standard pad placement, AP pad placement, or DSD, use that pad placement and energy setting for recurrent VF defibrillations

Venous Access

  • IO is faster than IV.
  • IV can follow IO.
  • Central venous access should be accomplished by a provider other than the code lead.

Drugs

  • Know your rhythm before giving drugs!  That tachycardia might be SVT or something that might not take kindly to a bolus of epinephrine
    • Epinephrine
      • Goal is for 3 doses in first 10 minutes.
      • Can give at 2,4, & 6-minute checks or whatever time interval is most easily accomplished.
      • After 10 minutes, goal is for Epi every 5 minutes.
    • Amiodarone (for VF)
      • Goal is for 2 doses in first 10 minutes.
      • 300mg first dose and 150mg second dose.
      • Can give at 2 & 6-minute checks or whatever time interval is most easily accomplished.

Code Lead & Code Scribe/Time Keeper

  • Confirm/ensure metronome use & appropriate CPR depth & rate.
  • Confirm/ensure appropriate BVM or BV ET Tube rate and volume.
  • Confirm/ensure ETCO2 connected and documented.
  • Notify team of impending compressor change and rhythm check 15 seconds prior to the end of the 2-minute cycle.
  • Confirm/ensure defibrillator is pre-charged.
  • Interpret rhythm.
  • Instruct defibrillator operator to deliver shock (or deliver shock if code lead is the operator) after confirming no team member is touching the patient.
  • Confirm/ensure resumption of CPR and BVM after rhythm check and/or defibrillation.
  • Request and confirm drug delivery at appropriately intervals.
  • Confirm/ensure documentation of rhythm(s) and drug doses.
  • Ensure all pauses are less than or equal to 5 seconds (use 5 sec verbal count down).
Dec 06, 2017
When can you shower after stitches?
14:55

In this episode

  • When is showering OK after stitches?
  • What type of ointment should be placed on a laceration to promote healing?
  • Is there an advantage to using antibiotic ointment over petroleum jelly on a non infected laceration?
  • How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?
  • What type suture to use for extensor tendon repair.

 

How long does one have to wait to take a shower after getting stitches?

  • There is limited data addressing this question, but based on the data we do have, showering after 48 hours is probably OK.
  • Even the NHS thinks so.
  • It may be perfectly fine to shower even sooner, but there's no evidence that gives a time cutoff for optional showering.
  • Note- showering does not mean submersion and it certainly doesn't mean getting in a hot tub. Second note-  the intent of this podcast it for medical providers to understand the medical literature and differing opinions on this question, not direct medical advice to patients.

 

What should you use to dress a wound?

  • Keep it moist. Don't let the wound dry. Lungs do the breathing, the wound needs to be smothered.
  • Petroleum jelly is fine. Antibiotic ointment on a non infected wound does not confer extra benefit and may actually lead to worse outcomes (hypersensitivity)
  • A 1995 study found that using antibiotic ointment on acutely sutured traumatic lacerations decreased the incidence of 'stitch abscess' but otherwise did not improve outcome for more severe infectious, such as cellulitis
  • Non adherent dressing, absorptive dressing, then overwrap. Many dressings incorporate all three of these in one product

 

How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?

  • Our interviewed expert says he repairs anything 25% or greater
  • In Roberts and Hedges it says repair is optional if the laceration is less than 50% of the cross-sectional area of the tendon.
  • A study that surveyed hand surgeons on flexor tendons found that some surgeons repair all of tendon lacerations, some only if they were more than 50% PMID: 7606610
  • If you’re wondering if that injured tendon needs repair, if it’s a little divot, probably not. When you get into the 25-50% range, possibly. If in doubt, splint and refer. 

What type suture to use for extensor tendon repair

  • Many options
  • Avoid Vicryl. It will break down too fast (2-3 weeks, not long enough for the tendon to heal)
  • Nylon commonly used
  • Our consultant prefers 4-0 Monocryl or PDS II. They will both dissolve but maintain tensile strength for a long enough the for the tendon to heal

 

References

Showering after laceration repair 

  1. Hsieh, Pei-Yin, et al. "Postoperative showering for clean and clean-contaminated wounds: a prospective, randomized controlled trial." Annals of surgery 263.5 (2016): 931-936. PMID:26655923
  2. Toon, Clare D., et al. "Early versus delayed post‐operative bathing or showering to prevent wound complications." The Cochrane Library (2015). Full text link
  3. Harrison, Conrad, Cian Wade, and Sinclair Gore. "Postoperative washing of sutured wounds." Annals of Medicine and Surgery 11 (2016): 36-38. Full text link

Keeping the wound moist to promote healing

  1. Dyson, Mary, et al. "Comparison of the effects of moist and dry conditions on dermal repair." Journal of investigative dermatology 91.5 (1988): 434-439. Full text link
  2. Dire, Daniel J., et al. "Prospective Evaluation of Topical Antibiotics for Preventing Infections in Uncomplicated Soft‐tissue Wounds Repaired in the ED." Academic Emergency Medicine 2.1 (1995): 4-10. PMID: 7606610

Contact Dermatitis Offenders

  1. Fransway, Anthony F., et al. "North American contact dermatitis group patch test results for 2007–2008." Dermatitis24.1 (2013): 10-21 PMID: 23340394
  2. Common contact allergens explained The Dermatologist 2014
Nov 27, 2017
3 Good Things
09:15

Every year on Thanksgiving I call up a few friends, usually different people each year, and tell them I am thankful for their friendship. Why do I do this? Is it for them, for them to get a warm glow of being appreciated? Not really, but that’s a nice extra effect. The goal of it is for me, to act as a reminder of the amazing things we get to experience in life, friendship being one of if not the greatest.

This is just one small thing on one day of the year. But what if you did something like this, just in your own head, every day?

The Study: A qualitative analysis of the Three Good Things intervention in healthcare workers. Full text link

The Intervention: Daily email reminders asking NICU staff to reflect on: what are the three things that went well today and what was your role in bringing them about.

The Results: There were three main themes in the answers

  • Having a good day at work 
  • Having supportive relationships
  • Making meaningful use of self-determined time

 

Mentioned in this podcast

Nov 23, 2017
Caring for Autistic Patients
24:46

If you’ve ever cared for an autistic patient, I suspect you have seen that there are stress points for you, the patient, the family, staff... everyone involved. A medical facility, especially a hospital or emergency department, is an extremely challenging environment for someone with autism. As medical providers, we have little to no training in this and usually the best we do is try and get through it. Surely there must be a better way of caring for autistic patients than what most of us do which is, let’s be honest, figuratively hold our breath and wait for it to be over.

Our guest today is Dr Heidi James. Heidi is a general practitioner working in Moncton, New Brunswick, Canada. She wears a lot of different hats in her career:  office practice, inpatient care, and medical education. But the focus of this conversation is her experience raising an autistic child, her son Jonas, specifically when Jonas the medical system meet.

 

Heidi James' 7 insights on caring for autistic (or non-verbal developmentally delayed) patients in the emergency department

 

We don't want to be in your department

  • We're only here because we've run out of options or ideas.
  • We will pay for this disruption in routine and upheaval for days to come in increased disruptive behaviours, bad sleep, and eating habits.
  • We don't necessarily know what's going on, but we know that something is going on. We're here because we're desperate.

 

Behavior is communication

  • Behavior if very often an attempt to communicate (and it may work well in their usual environment; i.e. banging your head against the wall to let your caregivers know you need to have a bowel movement) 
  • Communication: find out from caregiver how they communicate: Signs? Assisted communication devices? Picture exchange communication systems? Wing and a prayer?  
  • Receptive language is often better than expressive language.

 

Family or caregivers who know the patient are your allies

  • We're intimately attuned to subtle changes in behaviour, know the medical history, and can make a suggestion for how to minimize disruptive behaviors.
  • We're tired. Really tired. We're scared.  
  • More than a few of us have huge chips on our shoulders. It takes a ton of effort to be positive and pleasant when you spend hours a day cleaning up poop and years not sleeping. Remaining a non-bitter, decent human being takes hard, deliberate work.  Please be patient if we direct that anger/frustration at you

 

Quiet and secure is best

  • Noises, lights, new faces, temperature changes, strong emotions, new smells - any one of these, let alone all of the them, can overwhelm the nonverbal patient with sensory issues. The ED is a sensory nightmare.
  • It’s next to impossible in busy ER, but whatever accommodation can be made, try to place the patient in a quiet and secure spot.
  • The better the first experience, the easier any subsequent ones will be.
  • Calm voices when possible. Ask family member how to best approach pt.  
  • Many non-verbal patients are runners or elopers.  Please don't lose them. Restraints and sedation are better than finding someone on the highway.

 

Don't assume quality of life

  • I was in the ED doing an admission just after a man with severe autism coded. My colleague/friend wanted to talk about it.  She said,  "It's probably for the best, he had no quality of life".  I almost burst into tears.  While I know that that's part of the working through bad outcomes scenario, all I could think was "My son watches the same episode of Dora everyday, eats dog poop, sleeps 3-4 hours per night and is the freaking happiest person I know. He has an amazing quality of life by his standards, but a shitty one by other people's standards."
  • Keep these thoughts to yourself
  • We dedicate our lives to these people. They matter. Deeply. You invalidate us as well with those comments.

 

It's really hard for you

  • It is challenging to care for these patients in your department. They can't communicate.
  • Often it's the adult in crisis, and there's no family left anymore.
  • These pts are scary when they're agitated
  • You have to rely on tests and often poor collateral history
  • It's can seem like veterinary medicine-there will be no verbal cues to help you.
  • Remembering that these patients are, or hopefully were at some point, deeply loved might help you help them.

 

Ketamine

  • Have a low threshold for using ketamine to do procedures or perform diagnostic studies.
  • Before sedating, ask the caregivers if there are any other tests that need to be done (such as blood tests)

 

Bonus pearl

  • Remember to find out it if your patient with autism can/will take meds orally. Some won't swallow pills and need suspension. Other won't take pills or suspensions
Nov 20, 2017
Beating Stress and the Hot Offload with Ashley Liebig
35:46

Ashley Liebig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.

 

The Hot Offload

Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.

Hot offload Principles

  • A quick moment of diffusion
  • Get out the facts of what happened
  • What did you see, hear, taste, touch, smell immediately after the event
  • Reaffirming the memories and also exploring potentially false thought processes
  • Discuss feelings of guilt within the confines of the small unit that was involved

 

Hot Offload Steps

  • Bad thing happens
  • Team leader gets the group together
  • Group goes through what they saw-the raw facts of the event
  • In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference
  • Team leader does a quick check in - are you OK to continue working?
  • The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 

Ashley's three techniques for managing stress

Cognitive reframing

  • Change your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative
  • When bad things happen, there is a void created for you to fill with new opportunities
  • Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.

 

Visualization and rehearsal

  • This can inoculate you against the stress that arises in critical and high stakes situaitons

 

Mindfulness meditation

 

Ashley’s Credo

Work Hard, Be Respectful, Be Kind

 

Also mentioned in this podcast

Liz Crowe- we talk a lot about burnout but little regarding how to prevent it

Jocko Willink Podcast Clip

 

https://www.youtube.com/watch?v=IdTMDpizis8

Jocko Willink on the 12 aspects of an effective leader

Nov 13, 2017
Beating Stress and the Hot Offload with Ashley Leibig

Ashley Leibig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.

 

The Hot Offload

Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.

Hot offload Principles

  • A quick moment of diffusion
  • Get out the facts of what happened
  • What did you see, hear, taste, touch, smell immediately after the event
  • Reaffirming the memories and also exploring potentially false thought processes
  • Discuss feelings of guilt within the confines of the small unit that was involved

 

Hot Offload Steps

  • Bad thing happens
  • Team leader gets the group together
  • Group goes through what they saw-the raw facts of the event
  • In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference
  • Team leader does a quick check in - are you OK to continue working?
  • The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 

Ashley's three techniques for managing stress

Cognitive reframing

  • Change your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative
  • When bad things happen, there is a void created for you to fill with new opportunities
  • Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.

 

Visualization and rehearsal

  • This can inoculate you against the stress that arises in critical and high stakes situaitons

 

Mindfulness meditation

 

Ashley’s Credo

Work Hard, Be Respectful, Be Kind

 

Also mentioned in this podcast

Liz Crowe- we talk a lot about burnout but little regarding how to prevent it

Jocko Willink Podcast Clip

 

https://www.youtube.com/watch?v=IdTMDpizis8

Jocko Willink on the 12 aspects of an effective leader

Nov 13, 2017
Beating Stress and the Hot Offload with Ashley Leibig

Ashley Leibig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.

 

The Hot Offload

Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.

Hot offload Principles

  • A quick moment of diffusion
  • Get out the facts of what happened
  • What did you see, hear, taste, touch, smell immediately after the event
  • Reaffirming the memories and also exploring potentially false thought processes
  • Discuss feelings of guilt within the confines of the small unit that was involved

 

Hot Offload Steps

  • Bad thing happens
  • Team leader gets the group together
  • Group goes through what they saw-the raw facts of the event
  • In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference
  • Team leader does a quick check in - are you OK to continue working?
  • The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 

Ashley's three techniques for managing stress

Cognitive reframing

  • Change your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative
  • When bad things happen, there is a void created for you to fill with new opportunities
  • Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.

 

Visualization and rehearsal

  • This can inoculate you against the stress that arises in critical and high stakes situaitons

 

Mindfulness meditation

 

Ashley’s Credo

Work Hard, Be Respectful, Be Kind

 

Also mentioned in this podcast

Liz Crowe- we talk a lot about burnout but little regarding how to prevent it

Jocko Willink Podcast Clip

 

https://www.youtube.com/watch?v=IdTMDpizis8

Jocko Willink on the 12 aspects of an effective leader

Nov 13, 2017
Beating Stress and the Hot Offload with Ashley Leibig

Ashley Leibig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.

 

The Hot Offload

Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.

Hot offload Principles

  • A quick moment of diffusion
  • Get out the facts of what happened
  • What did you see, hear, taste, touch, smell immediately after the event
  • Reaffirming the memories and also exploring potentially false thought processes
  • Discuss feelings of guilt within the confines of the small unit that was involved

 

Hot Offload Steps

  • Bad thing happens
  • Team leader gets the group together
  • Group goes through what they saw-the raw facts of the event
  • In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference
  • Team leader does a quick check in - are you OK to continue working?
  • The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 

Ashley's three techniques for managing stress

Cognitive reframing

  • Change your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative
  • When bad things happen, there is a void created for you to fill with new opportunities
  • Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.

 

Visualization and rehearsal

  • This can inoculate you against the stress that arises in critical and high stakes situaitons

 

Mindfulness meditation

 

Ashley’s Credo

Work Hard, Be Respectful, Be Kind

 

Also mentioned in this podcast

Liz Crowe- we talk a lot about burnout but little regarding how to prevent it

Jocko Willink Podcast Clip

 

https://www.youtube.com/watch?v=IdTMDpizis8

Jocko Willink on the 12 aspects of an effective leader

Nov 13, 2017
Beating Stress and the Hot Offload with Ashley Leibig

Ashley Leibig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.

 

The Hot Offload

Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.

Hot offload Principles

  • A quick moment of diffusion
  • Get out the facts of what happened
  • What did you see, hear, taste, touch, smell immediately after the event
  • Reaffirming the memories and also exploring potentially false thought processes
  • Discuss feelings of guilt within the confines of the small unit that was involved

 

Hot Offload Steps

  • Bad thing happens
  • Team leader gets the group together
  • Group goes through what they saw-the raw facts of the event
  • In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference
  • Team leader does a quick check in - are you OK to continue working?
  • The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event

 

Ashley's three techniques for managing stress

Cognitive reframing

  • Change your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative
  • When bad things happen, there is a void created for you to fill with new opportunities
  • Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.

 

Visualization and rehearsal

  • This can inoculate you against the stress that arises in critical and high stakes situaitons

 

Mindfulness meditation

 

Ashley’s Credo

Work Hard, Be Respectful, Be Kind

 

Also mentioned in this podcast

Liz Crowe- we talk a lot about burnout but little regarding how to prevent it

Jocko Willink Podcast Clip

 

https://www.youtube.com/watch?v=IdTMDpizis8

Jocko Willink on the 12 aspects of an effective leader

Nov 13, 2017
Gunshot to the Groin with Kenji Inaba
23:44

Dr Kenji Inaba is a trauma surgeon at the University of Southern California. He is also the director of their surgical ICU,  one of the most widely published trauma researchers with over 400 publications, and a reserve officer with the Los Angeles police department. You'd think with that kind of background, he would be macho, arrogant, and in your face about how awesome he is but, in fact, he’s just the opposite. Humble, kind, thoughtful and just about the greatest guy you’ll ever meet. In today's episode, we discuss junctional bleeding:  Bleeding from an area that is a junction of an extremity and the torso (and neck) that is not amenable to hemorrhage control by tourniquet.

 

A patient arrives with a gunshot wound to the groin. The paramedic is holding pressure with a stack of gauze but it's obvious that bleeding isn't controlled. Here are the next steps

  • Remove the gauze
  • Assess the injury
  • Where is the hole and what kind of bleeding is coming up?
  • If there is sustained bleeding, apply pressure to the specific point of bleeding  - ideal if you can compress proximal to the hemorrhage site. Using diffuse pressure with the palm of your hand in the general vicinity of bleeding may be less effective.
  • If bleeding continues or you need to free up your hands, consider placing a Foley catheter in the wound.
  • The best kind of wound for a foley catheter is one that's just big enough to allow entry of the catheter (so it balloon stays in the cavity once it's inflated)

 

Placement of a Foley catheter to control junctional bleeding as described by Kenji Inaba

  • Use the largest Foley catheter that you have. It's not the size of the catheter that's so important, it's that larger catheters will have more balloon volume
  • Ask for mulipies catheters because one might not provide hemostasis
  • Place the Foley in the hole (bullet or stab wound) and go all the way into the bleeding cavity. Slip the catheter in as deep as it will go
  • Inflate the balloon with saline (or some sort of fluid). If the bleeding hasn't stopped after 20-30 cc of fluid in the balloon, you may need to place a second catheter
  • Clamp across the Foley tube (so blood doesn't come back through the catheter)
  • May need to stitch the skin so the balloon doesn't pop out
  • Another option that Kenji uses are the XSTAT pellets

 

Kenji's opinion on junctional tourniquets (examples Combat ready clamp, SAM junctional tourniquet )

  • They work
  • Some are quite bulky, a lot of material in your way during a resuscitation
  • If you work in a place were you need to apply pressure and get your hands free and have the capacity to store them, not a bad idea.
  • In Kenji's ED, OR, and ICU, he doesn't see much return on investment

 

Nov 06, 2017
Long term health of patients vs. Short term risk to doctors
36:25

What is your real motivation when making medical decisions? Is it 'what's in the patient's best interest' or is it 'what will keep me from getting sued'? The reflexive answer is, of course,  the former, but if you really do some soul-searching, there's probably a bit of the latter as well. In this episode, Mike Weinstock, author of Bouncebacks, and Bouncebacks Pediatrics, discusses why we sometimes have our priorities misaligned with the patient's and how that doesn't need to be the case.

 

Along with Amal Mattu and Erik Hess, Mike has recently published an article titled How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? (link). The study's conclusion is this:  A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician’s short-term concern of their own risk to the patient’s long term health. 

An example of where this sort of thinking comes into play is with the evaluation of patients with chest pain. Should they be admitted to the hospital? Are they safe to go home? Before we can answer either of those questions, we first need to address the elephant in the room...

 

What is an acceptable miss rate for chest pain?

Than, M., et al. "What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the Emergency Department?: a clinical survey." International journal of cardiology 166.3 (2013): 752. PMID:23084108

  • Survey of 1029 emergency department clinicians.
    • 395 comfortable with a 1-2% miss rate
    • 267 comfortable with < 1%
    • 331 only comfortable w < 0.1%

Putting that last number in perspective, that's admitting 1000 patients to find one with cardiac disease. Is that a good return on investment or wise stewardship of health care resources? I think the answer is no. There are several reasons for this. The first is that being admitted to the hospital is not a benign event.

 

What is the chance that a patient will be harmed by hospitalization?

James, John T. "A new, evidence-based estimate of patient harms associated with hospital care." Journal of patient safety 9.3 (2013): 122-128. PMID: 23860193

  • Estimates a lower limit of over 200,000 deaths per year related to the deleterious effects of hospitalization

 

It's no secret that hospitalization can be dangerous, but it can also be extremely helpful in the properly patient. So in a patient with chest pain who has two negative troponins and a non ischemic EKG, what is the short term risk of clinically relevant adverse cardiac event (CRACE)? In other words, if we hospitalize patients with these factors (negative EKG and enzymes) what is the likelihood that something bad will happen in the next few days that could be mitigated by hospitalization?

Weinstock, Michael B., et al. "Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission." JAMA internal medicine 175.7 (2015): 1207-1212. PMID:25985100

  • This study sought to determine the risk of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization in patients with negative serial troponin, non concerning initial ED vital signs, and nonischemic, interpretable EKG.
  • Over 7,000 chest pain patients admitted (non ischemic EKG, negative serial troponin)
  • 0.06% incidence of CRACE during the hospitalization
  • So over the few days that a patient with non corning EKG and negative enzymes is in the hospital, there was a 6 in 10,000 chance of a catastrophic outcome
  • This is different than what's being asked by the HEART score. HEART is looking for the risk of major adverse cardiac event (MACE) in 6 weeks.

 

Taking all of this into account, how does Dr. Weinstock approach shared decision making?

  • If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available
  • He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk
  • The Weinstock Credo: Don't practice defensive medicine. Document "defensibly"

 

Also mentioned in this episode

  • Brown, Terrence W., et al. "An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers." Academic Emergency Medicine17.5 (2010): 553-560. Full article link
  • Have a good time, all the time

 

Editors note: Show notes are meant to complement the podcast and do not represent a complete synopsis of what is contained in the audio.

 

Oct 30, 2017
Precise Communication
13:59

Have you ever watched a volleyball game and seen the ball fall between two players? What happened there? It was probably inadequate or insufficient communication as to who was going to make the play. The same thing happens in almost every professional arena: mistakes are made because of poor communication. In this episode we discuss three tools to improve how we relay information to each other, eliminate ambiguity, and the biggest goal of all - improve patient safety.

Tools discussed in this show

  • Three way repeat backs
  • Phonetic clarification
  • Clarifying language with numbers
  • Using a dry erase board in the resus bay
  • Posters in the resus bay with simple but important checklists

Links mentioned in this show

Three way repeat backs

Sender: Gives the initial information

Receiver: Repeats information back

Sender: if the repeated information is correct, responds with, "That's correct."

Using the phrase "that's correct" takes away the vagueness that can happen with words such as right, OK, yup, got it, etc.

Phonetic clarification

Use the phonetic alphabet to spell out easily misspelled or misunderstood words. For example, my name is often misspelled, so I will say, "It's Orman, O-R-Mike-Apple-Nickel." There are many phonetic alphabets out there, and you don't have to use one in particular. Just use what makes sense to you and is clear to the listener.

Clarifying language with numbers

When there are numbers that sound alike such as 15 and 50, say the number and then say the digit. "Please give fifteen milligrams of drug X, that's one five milligrams"

Using a dry erase board in the resus bay

I use the board to write my induction, paralytic, and post intubation medication plan. This is discussed out loud with the team while I'm writing it out. I use Reuben Strayer's intubation checklist as my reference. Here is an example (written on my board at home, not an actual patient).

Posters in the resus bay with simple but important checklists

It's amazing how much can be missed in a trauma resuscitation. Going back through the primary and secondary survey, step by step, can help organize your management and keep you from missing critical issues. Here are two posters in my favorite resus bay:

Oct 23, 2017
Alcohol, c-spines, and lots of pus
43:09

A day late and a dollar short, but here it is, the Ercast summer Journal Club. As per usual, boy genius Adam Rowh, MD is in the house to give his take on the medical literature. In this episode, we discuss

  • Cervical spine clearance in the intoxicated patient (can you remove the collar if they have a negative CT?)
  • Is there utility to giving antibiotics to patients with simple cutaneous abscess?
  • Thrombolytics don't give long term benefit to patients with submissive pulmonary embolism
  • Haloperidol is good for what ails you (if you have gastroparesis)
  • Steroids for bronchitis

Also mentioned in this show

  • Boneyard RPM IPA
  • Follow us on Facebook. It's the new information portal for updates, questions, etc. If you want to contact me personally, use the contact link on this webstie
  • Now on to the education....

 

Do patients with simple abscesses need antibiotics?

The answer for much of the antibiotic era has been no. I and D is sufficient treatment. But with the rise of MRSA, that thinking has been questioned. A paper by Talan in 2016 investigating TMP-Sulfa vs placebo for uncomplicated skin abscess suggested that TMP-Sulfa conferred a higher cure rate after I and D. Now comes a study of similar ilk but an additional treatment arm.

Study Basics

  • Title: Daum, Robert S., et al. "A placebo-controlled trial of antibiotics for smaller skin abscesses." New England Journal of Medicine376.26 (2017): 2545-2555.PMID: 28657870
  • The patients: 786 patients with abscesses 5 cm diameter or less.
  • The treatment: After I and D placebo, patients received either placebo, clindamycin, or TMP-Sulfa
  • Primary endpoint: Clinical cure. This includes improvement of the treated abscess but ALSO no new abscesses forming elsewhere (that will come into play later)
  • The results: Compared to placebo, both clindamycin and TMP-Sulfa improved short-term outcome. Clinical cure was 83% clinda, 81% TMP-Sulfa, and 69% placebo. NNT of 8. There was not much difference between the different antibiotics, but big a difference compared to placebo

Looking under the hood (examining the details)

  • Treatment effect was only when staph was the culprit. When there was no staph isolated, the outcome was not influenced by antibiotics
  • Average surrounding erythema was over 2cm. This suggests that there was some cellulitis in these patients. Prior to this study, the common practice was to treat these patients with antibiotics. We recognize that it's not always easy to delineate between redness from the abscess itself and spreading cellulitis. Our point of contention, that these abscesses also had cellulitis, may be making a big deal out of a small thing (or it could be the most legitimate criticism of the paper).
  • Treatment failure was mostly formation of new abscess and not worsening of the original abscess. While this is certainly a measurable effect, is it really a treatment failure? We argue that it is not. What's probably happening here is decolonization on some level. That is pure conjecture, of course, and it's certainly possible that there was autioinfection from the main abscess. 
  • Our bias:  We don’t want to give extra antibiotics. Coming into this paper, we were looking for any faults in the study that could confirm an 'antibiotic stewardship' approach.  If this was a paper showing even a small benefit for thrombolysis in the treatment of pulmonary embolism, we would look at in the exact opposite manner-where is the signal of benefit that says we might help patients.  
  • Will this change our management? Both Rob and Adam say it will not. We will continue to treat simple cutaneous abscesses (without surrounding erythema) with I and D alone. If the abscess is a recurrence or it is a patient with multiple abscesses, we will consider antibiotics.

 

C-spine clearance in the intoxicated patient

An intoxicated patient with moderate trauma has a pristine looking, completely normal, CT of the cervical spine. Do we need them to continue wearing their cervical collar until clinical sobriety? Enter our next study

Study Basics

  • Title: Schreiber, Martin, et al. "Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey." (2017). PMID: 28723840
  • The patients: About 10,000 moderate trauma patients, of who approx  3000 were TOX positive  (alcohol, drugs, or both). The average injury severity score was 11 (moderate trauma).
  • Intervention: CT cervical spine
  • Primary outcomes: Incidence and type of cervical spine injuries, accuracy of CT scan, and the impact of TOX+ on the time to cervical spine clearance
  • The results: In the TOX positive  group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable cervical spine injuries missed by CT (NPV=100%). One patient in the Tox + but CT negative group had a central cord injury. When CT cervical spine was negative, TOX + led to longer immobilization vs sober patients (mean 8 hrs vs 2 hrs, p<0.01), and prolonged immobilization (>12hrs) in 25%.
  • Author take home: CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization

This conclusion mirrors the EAST guidelines on cervical spine collar clearance in the obtunded adult blunt trauma patient:

In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. This conditional recommendation is based on very low-quality evidence but places a strong emphasis on the high negative predictive value of high quality CT imaging in excluding the critically important unstable C-spine injury.

Haloperidol for Vomiting

The lament for droperidol's absence from our pharmacopeia continues unabated, yet there is another shining star: haloperidol. What's old is new when it comes to treating severe nausea and vomiting. Long recognized in the palliative care world as the cat's pajamas for management of nausea, haloperidol is finally getting the recognition it deserves.

Study Basics:

The study: Ramirez, R., et al. "Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department." The American journal of emergency medicine (2017). PMID:28320545

The patients: Retrospective study of 52 patients with diabetic gastroparesis treated with 5mg IM haloperidol.

The comparator group: The SAME PATIENTS on ED visits when they didn’t get haloperidol! You can't get better matching characteristics than that.

The results: Using haloperidol in this group of patients decreased amount of opiates given and admissions but not ED or hospital length of stay. There were no complications seen in patients given haloperidol

Systemic lytics don't work for intermediate risk PE

This has been a subject of much debate over the past decade and there has been signal that there may be a benefit in function outcome when thrombolytics are given to so-called intermediate risk pulmonary emboli- not hypotensive but right ventricular dysfunction and a positive biomarker. The biggest research article to date says lytics don't improve outcome.

Study Basics

The study: Konstantinides, Stavros V., et al. "Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism." Journal of the American College of Cardiology 69.12 (2017): 1536-1544. PMID:28335835

The patients: About 700 patients with intermediate risk PE given either Tenecteplase of placebo. Intermediate risk PE defined as RV dysfunction confirmed by echocardiography or spiral computed tomography of the chest. Myocardial injury confirmed by a positive troponin I or T test result.

The results: At 3 year follow up, there was no significant difference in mortality, functional limitations, pulmonary HTN, or RV dysfunction.

Our take home: When we first saw this paper, we were giddy because here was evidence that would show, once and for all, that lytics were an effective treatment for this cohort. The cold hard data says quite the opposite: lytics don’t make a difference in long term outcome. The best evidence we have to date suggests that there is no justification to give systemic thrombolysis to a stable patient with intermediate risk PE. Will catheter directed lysis prove any better, or are there certain high risk groups under the 'intermediate' umbrella who would benefit? Time will tell. 

 

Prednisone for cough

Study Basics

The study: Hay, Alastair D., et al. "Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial." Jama 318.8 (2017): 721-730. PMID:28829884

The patients: 400 patients with cough for less than a month and at least 1 lower tract symptom like phlegm, chest pain, wheezing or SOB in the past day. Patients received either 40 mg of prednisolone or placebo daily for 5 days. The primary outcomes were duration of cough and mean severity of symptoms on days 2 to 4.

The results: Steroids did not make a difference

Our take home: WTF!? Of course steroids didn’t work! Only 6 percent of patients had wheezing and only a handful had crackles.  Does a patient with an undifferentiated acute viral respiratory infection benefit from steroids? Apparently not. We tend to prescribe patients to these patients who DO have wheezing, but this supports our practice of not using them in patients who don't. 

Oct 20, 2017
What you don't know about Wernicke's encephalopathy
17:01

Megan Spyres, toxicologist and emergency physician at LA County-USC, gives a primer on diagnosing and treating Wernicke's encephalopathy. The title of this post "What you don't know about Wernicke's encephalopathy" is more from my perspective than a commentary on what you, the listener, may know. After all, you might be a genius when it comes to this disease. For me, this has always been confusing and difficult to diagnose. So let's sharpen our clinical acumen and learn why neglecting thiamine can be a really bad thing. Special thanks to Dr. Anand Swaminathan for his journalistic excellence in putting together this interview.

 

Pathophysiology

  • secondary to thiamine deficiency (vitamin B1). Thiamine is a cofactor for pyruvate dehydrogenase. This enzyme is needed to take glucose from anaerobic glycolysis into the Krebs cycle (where we make the majority of our ATP)
  • pyruvate dehydrogenase converts pyruvate (the end product of glucose metabolism in glycolysis) to acetyl co-A. Acetyl co-A is the entry point into the Krebs Cycle.
  • if there is no thiamine, there is no Acetyl co-A... no Krebs Cycle... no ATP.
  • The heart and brain get quite upset and function poorly when they don’t have ATP
  • we only have a few weeks of thiamine reserves (best case scenario)

Clinical Presentations

Cardiac: Wet beriberi

  • high output heart failure. Fatigue SOB, peripheral edema

CNS: Wernicke's encephalopathy

  • ophthalmoplegia
  • ataxia
  • altered mental status/confusion/memory problems

Extra nuggets

  • It would be nice, in a clinical sense, if patients presented with all elements of this triad, but the overwhelming majority do not (there may be just one or two)
  • Wernicke's encephalopathy can progress to Korsakoff syndrome - an irreversible anterograde amnesia. May also include confabulation, apathy, lack of insight.
  • In addition to the above findings, there may also be absent reflexes on physical exam

How common is Wernicke's encephalopathy?

  • estimated to be present in 2% of the US population

Who is at risk?

  • insufficient intake
  • insufficient absorption
  • enhanced elimination

Specific groups who are at risk for thiamine deficiency

  • Chronic Alcoholics: poor nutrition, poor absorption
  • Bariatric surgery, AIDS, malignancy, hyperemesis gravidarum
  • Insufficient intake: eating disorders, prisoners, institutionalized elderly
  • Enhanced elimination: patients on furosemide

Evaluating for Wernicke's encephalopathy

  • It’s an easy disease to overlook. Consider in an alcoholic patients with multiple presentations with confusion
  • Do a good neurologic exam. Don’t blow off persistent ataxia, especially when the intoxication has resolved to the point where the patient can be discharged
  • In 1997, Caine et al suggested that the diagnosis could be made with two or more of the following:
  1. dietary deficiencies
  2. oculomotor abnormalities
  3. cerebellar dysfunction
  4. either an altered mental state or mild memory impairment

Treatment

  • give thiamine
  • in the presence of ETOH, thiamine absorption is reduced by up to 50%. Don't think you will be able to rapidly correct this disease with PO treatment alone
  • 100mg IV is good for prevention and might protect patients for at least a week. This dose is not, however, considered sufficient for treatment
  • treat with  500mg IV thiamine three times daily  for 2-3 days, then 250mg IV TID for 3-5 days

Does thiamine need to be given before glucose?

  • a glucose load will increase thiamine requirements.
  • historically, it has been thought that giving a load of glucose (or dextrose) might ‘push patients over the edge’ into encephalopathy. There’s no evidence that this occurs in patients who aren’t already overtly thiamine deficient.

Bottom Line: Wernickes encephalopathy is easy to treat but also easy to miss. When we miss it, our patients can suffer

Sep 30, 2017
Conquering Night Shifts and Soft Tissue Ultrasound with Mike Mallin
43:22

Mike Mallin is a legend in emergency ultrasound but, by day, he's a regular guy and community ED doc. In this episode, Mike and Rob talk about

  • making the change from an academic to community medicine job
  • working in a place that sparks joy
  • working locum tenens
  • soft tissue ultrasound looking for abscess
  • placing peripheral IV catheters under ultrasound guidacne
  • how they approach night shifts (both single and stacks of shifts)
  • patient handoffs

 

 

Soft tissue ultrasound

This is one of Mike Mallin's favorite exams, because no matter how good he thinks he is at guessing how much or if any pus is underneath the skin, he's often surprised when looking with ultrasound. A landmark study by Tayal in 2006 found that the introduction of soft tissue ultrasound into an ED evaluation for a skin and soft tissue infection changed management 56% of the time. Some patients who docs thought needed drainage didn’t and some that docs did not think needed drainage did. 

Pearls when looking for an abscess

Compress with the probe: Pus can look a lot like surrounding tissue - especially nasty, thick MRSA pus. Sometimes the only way to see the pus pocket is to compress. What you're looking for is the swirl sign  (sometimes called the 'squish sign')

 

Use Color Doppler. Make sure that dark pocket of fluid you’re about to incise isn’t a AV fistula, or a random artery or vein. An 11 blade in a vascular structure is considered bad form.

Look for Air: While looking at the infection, beware of air bubbles in the skin, they- along with fluid tracking on the fascial planes, can tip you off to gas forming bacteria. While that doesn’t always mean necrotizing fasciitis, it should get your attention. Unless there is already a hole in the skin for air to get in, these patients probably need a surgeon's hands on them.

Soft tissue air. Ultrasound from Joseph Minardi

Another example of necrotizing fasciitis on US from the EDE blog

 

Rob's Patient Handoff Macro

 This is a [  ] year old [  ] who presented to the emergency department with a chief complaint of [ ].  Patient care transferred from Dr. [ ] at [ ].   Presenting symptoms: [ ]  Workup to this point: [ ]  Pending studies: [ ]  Plan at time of sign out: [ ]    Study results: [ ]  Patient reassessment: [ ]  Plan: [ ] 
Sep 20, 2017
Getting Sued
32:24

This is not an easy episode. It's not easy because a doctor gets named in a lawsuit, a patient has a bad outcome, and it openly discusses some of the systems failures we have in medicine. If that's enough to turn you off, close the page and go about your day. You'll probably be happier for it. 

Still here? Well, here's what we've got... Cam Berg is arguably one of the brightest stars in emergency medicine (or all of medicine if you ask me.) Even that level of excellence, however, didn't stop Cam from being named in a lawsuit when a patient had a catastrophic outcome. This case involves a series of events that include: hypertension, IV hydralazine for asymptomatic hypertension, boarded patients, stroke, thrombolytics, brain bleeds, and the collateral effects of getting sued.

Jul 25, 2017
Peeing Blood and the Pesky Erection
42:14

Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer.

Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised. 

Stuff Adam and Rob have discovered recently and are really digging

Rob

  1. Dermastent
  2. Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls of heavenly delight I use during shifts (and home, and exercise, and so on). 
  3. This Tono-Pen

Adam

  1. Wearing gloves while eating a sandwich
  2. Topical TXA for a persistently bleeding biopsy site in a patient taking rivaroxaban
  3. Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in the nebulizer basin either with or without bronchodilator

Treating Priapism

  1. Patient presents with persistent painful penile erection.
  2. Anesthetize the penis, sterilize the area of corpus cavernosum you are going to drain. How one numbs the penis for this procedure is a matter of great debate, meaning there is no best answer. Some espouse a dorsal penile nerve block while others favor local anesthesia at the site of injection. I prefer local infiltration at the site of injection and have found it to be more reliable than trying to get the whole penis numb.
  3. Mix up a solution of dilute phenylephrine. This is your vasoconstrictive agent. The end goal is to dilute 1mg of pheynylephrine with 10 mL of normal saline (or 9.9 mL if you're a purist). This gives a concentration of 100mcg/mL ( the recommended dose from the American Urologic Association is actually 100-500mcg/mL, giving a significant margin of error). The phenylephrine you have in your department is most likely 10mg/mL, so you will end up drawing a tenth of a mL.  Getting the vasoconstrictive agent mixture correct seems to be one of the more anxiety provoking aspects of this procedure.  There are lots of ways to make your mixture, the most straightforward method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB syringe. Into that same syringe, draw up 0.9cc of saline. Now you have a total of 1cc total volume. Add that to 9cc of saline and you are at the desired 100mcg/mL concentration. When you've got this task completed, set this syringe to the side. You're going to need it shortly. Pro tip: label the syringe after creating the dilute phenylephrine.
  4. Attach an 18 or 19 g butterfly needle to a large syringe
  5. Inset the butterfly needle into the corpus cavernousum at the lateral base of the penis. It doesn't matter which side, each side connects to the other. Your entry point is either 10 or 2 o'clock. Pull back on the syringe while advancing the needle. Once you get blood back, stop- that is your needle depth for the remainder of the procedure. Pro tip: Even though you might be tempted to use the biggest syringe you can find, like a 60cc behemoth, stick with a 20cc syringe. The bigger syringe might create too much suction, which can ruin the day.
  6. Aspirate blood. This will look thick and dark (chocolate syrup, old motor oil dark). The amount you'll be able to aspirate varies, but it's usually  around 10-20cc.
  7. Keep the butterfly needle in place while you  unscrew the aspiration syringe from the proximal port and replace it with your syringe with dilute pheynlephrine. Better yet, use a 3 way stopcock. On one port, you have your vasoconstrictive agent ready to go. On the other port, you can easily work the replacement of fresh aspiration syringes. Having an assistant for syringe management makes this process much easier (and safer as you're less likely to change the position/depth of the butterfly needle while fiddling about with the syringes)
  8. Inject 1mL of dilute phenylephrine into the penis. Pro tip that's probably not actually a pro tip: After injection, massage the penile shaft to get more diffuse spread of the vasoconstrictive agent. Does this massaging actually improve outcome? Unknown.
  9. The penis may now become flaccid or it may still be tumescent. If the erection does not resolve, repeat steps 6 through 8. This may take several rounds of aspiration and injection of vasoconstrictive agent.
  10. When is the penis flaccid enough that you can stop? Some say when the blood aspirated, others when the penis stays flaccid. There's not an absolute demarcation line, it's more of Justice Potter Stewart's "I know it when I see it."
  11. Milk the penis from tip to base to squeeze out residual blood. The patient can do this as well. Pro tip: After you've finished the above steps, wrap the penis in a compressive bandage like an ace wrap or Coban to prevent reaccumulation of blood.
  12. If you are unable to resolve the priapism with this technique, urology may need to take the patient to the OR

Hematuria

When a patient presents with hematuria, what are the key questions to ask in the ED?

  1. Is there any associated pain? If so, you may be dealing with a stone, infection, etc.
  2. If it is painless, which is the most common situation we see, the big question is whether or not the patient is in CLOT RETENTION. Are they retaining urine or can they pee freely? The test for this is a post void residual bladder scan
  3. If they are peeing blood, but not in clot retention, they can follow up with urology as an outpatient for CT urogram, cystourethrotgam, and advanced urine testing
  4. If they are in CLOT RETENTION, you need to drain the bladder. What often gets placed is a three way catheter. These catheters are great for irrigating the bladder, but may not be sufficient to evacuate clots.
  5. Dr. Shaffer recommends placing a 22 Fr 6 eye catheter. Here's an example of a 6 eye catheter (we have no connection with the company selling these in the link provided)
  6. Once the 6 eye catheter is in, hand irrigate the bladder until there are no clots
  7. If the urine clears (cranberry colored or lighter), pull the catheter and give a voiding trial
  8. If the urine is still bloody, NOW place a 3 way catheter and admit the patient for continuous bladder irrigation. They get admitted to see if they go back into clot retention.
  9. Jess Mason and urologist Eamonn Bahnson have a master class review of placing the difficult foley in the August 2017 edition of EMRAP.

Interstitial cystitis

  1. Evaluate for and treat infection
  2. Manage pain
  3. Make sure they're on an anticholinergic
  4. Follow up with urology

 

Jul 02, 2017
When Breath Becomes Air. Lucy Kalanithi Interview
23:47

Last summer I took a road trip to Canada and during the drive I listened to the book When Breath Becomes Air. That was a year ago, and I still think about that book, almost daily. When Breath Becomes Air is the autobiographical account of the final 2 years of neurosurgeon Paul Kalanithi life. Paul was in residency, age 36,  when he was diagnosed with stage 4 lung cancer, to which he ultimately succumbed. The book tells the tale of the nuts and bolts of his treatment, his transformation from doctor to patient, but more importantly, it was about time. His time was limited, just like all our time is limited, but with a terminal diagnosis, in the face of death, he asked the question, “What makes life worth living?” What do you do with your time, what’s important? Do you work if you’re physically able, do you spend all of your remaining time with your family? Time can feel infinite, especially when you’re young, but as individuals, time is our most precious resource, and it’s a nonrenewable resource. So how do you spend it?

Paul died before completing his manuscript and his wife, Lucy Kalanithi, a Stanford internist, put it together and wrote the epilogue. Since then, she’s become a passionate a vocal advocate for helping others choose the heath care and end of life experiences that best align with their values.  In May 2017, at Essentials of Emergency Medicine in Las Vegas, I sat down with Lucy for a live interview on why she does what she does, some of the experiences she and Paul when through, how her perspectives on life and medicine have changed, what she thinks when she sees a patient with the sniffles, what if everyone died like a doctor, and reframing the question where there is a devastating diagnosis or even a run of bad luck from, “Why me?” to “Why not me?” I’d encourage you to listen to this particular podcast episode all the way through and not in small chunks. It builds momentum as the conversation progresses and at the end, culminates in what are some beautiful words of wisdom...Life is not about avoiding suffering.

Jun 24, 2017
Spring 2017 Journal Club
31:33

It may be summer (in the northern hemisphere), but that doesn't mean we can talk all the goodness that was our spring journal club. As usual, Adam Rowh slayed the beer selection with a killer Scottish ale as well as these lovely articles. Enjoy....

The papers

Less is more for low back pain

Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530.

Full article link

 

How worried should you (and the patient) be about discharge glucose?

Driver, Brian E., et al. "Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia." Annals of emergency medicine 68.6 (2016): 697-705.

Full article link

 

Ibuprofen and fracture healing

DePeter, Kerrin C., et al. "Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?." The Journal of emergency medicine 52.4 (2017): 426-432.

Full article link via Broome Australia's favorite ginger raconteur, Casey Parker

 

Ketorolac's therapeutic ceiling

Motov, Sergey, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial." Annals of Emergency Medicine (2016).

Full article link from, yep, once again, Casey Parker

 

Concussion, Rest, and the 8th Dimension

Grool, Anne M., et al. "Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents." Jama 316.23 (2016): 2504-2514.

Full article link

Thomas, Danny George, et al. "Benefits of strict rest after acute concussion: a randomized controlled trial." Pediatrics (2015): peds-2014.

Full article link

Jun 21, 2017
How to learn from a lecture
26:37

Amal Mattu stops by to talk about the best way to get the most from attending (as well as giving) a lecture. Hint, it's not the the transfer of information. Amal says that lectures have one of two purposes: to persuade or  inspire.

To get the most out of attending a lecture

  • take notes
  • no more than three take home points per talk
  • when you get back home, review your notes and read the handout, source material, etc
  • ask questions if possible
  • do not sit passively and try to absorb information by some sort of osmotic wizardry

To get the most out of giving a lecture

  • simple slides without too much or complex information
  • no more than one take home point every 10 minutes
  • engage the audience in the discussion
  • repeatedly reinforce the take home points
  • practice and then practice a bit more

 

Links discussed in this show

P Cubed Presentations Link

Essentials of Emergency Medicine Link

Confound definition

Mar 24, 2017
Examining mental health patients
08:18

When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental health part of the exam, what do you look for and how do you document it? There are all sorts of different ways to go about it, but one I find particularly useful is the mental status exam. Not alert and oriented times 3 or GCS 15 mental status exam, but the one that goes by the title Mental Status Exam.

 

It’s an exam that is carried out by your powers of observation. There is no stethoscope, no palpation involved. You are just watching and listening. What we’re going to go through is my adaptation of the full Mental Status Exam. It’s been tweaked, added, subtracted, and modified over the years and I’ve found it helps to break down the aspects of a patient's appearance and behavior in a way that makes sense (at least to me). As I was putting this podcast together, I thought about some of the dogma that goes into any structured evaluation, meaning: these are the core elements of the exam and that’s all there is to it; it’s always been done this way and this is the best way. But there really is no evidence that performing a mental status exam in one particular way versus another improves outcome. The same could be said for many parts of the physical exam. Much like the suicide risk assessment template I use, I see this as a way to make sense of what is often an incredibly complex emergency department presentation. 

 

ED Mental Status Exam

The constituent elements are: Mood, affect, eye contact, attending to internal stimuli, thought process and content, speech pattern, grooming, and presence or absence of suicidal ideation. Let’s break that down piece by piece.

Mood and affect. These terms are confusing because they are synonyms and don’t they kind of mean the same thing? Think of it this way: mood is how the patient tells you they’re feeling and affect is what you observe. For example, mood: I am anxious, I am depressed, I am crawling out of my skin, etc. Affect: what do you observe about their emotional state. Do they appear anxious, depressed, flattened, blunted, restricted, is their affect exaggerated? Is it congruent with their mood and the current situation?

Eye contact. Do they look you in the eye, are they engaged in the conversation? Are they withdrawn and looking down/away?

Attending to internal stimuli. This is something we usually equate with a psychotic state: auditory and/or visual hallucinations. It’s being generated by their mind as opposed to an external force. Sometimes it’s pretty clear. They’re intently looking around in an empty room or carrying on a conversation when there’s no one there. Sometimes it can be more subtle and only manifested as inattentiveness with latency in answering a question or following an instruction (although that latency can have many other causes).

Thought process and content.  Is their thought pattern organized or disorganized? Are there delusions or obsessions?

Speech. Is it normal content and cadence? Pressured? Super loud or super soft? Is it tangential? Tangential speech is often categorized as a thought process because it is a variant of disorganized thought, but I put it here because it's such a distinct speech pattern.

Grooming: Well kempt? Disheveled? Clothing encrusted with urine and feces?

Suicidal ideation: Present, absent, passive, active with a plan?

There are many other parts of the full Mental Status Exam, but those are the high yield aspects that I use, or at least start with. Some things like 'insight' I put in the suicide risk assessment, because that takes an involved conversation with more direct engagement to tease out, rather than easily observe.

Putting it all together.

A person who is having no issues at all, completely normal exam. 

Mood, baseline and neutral per patient. Affect, neutral and congruent with mood. Eye contact good. He does not appear to be attending to internal stimuli. Thought process and content normal. Answers all questions appropriately. Speech is normal content and not tangential. Grooming well kempt. Suicidal ideation denies.

Or a psychotic patient may have an exam that looks something like this. 

Mood is depressed. Affect flattened. Poor eye contact. He appears to be attending to internal stimuli and is looking about the room during our conversation. He periodically turns his head to the side and yells obscenities. Thought process is disorganized and there are several seconds of latency in answering questions. There is a delusion of persecution where the patient reports being followed by the government. Speech is slowed cadence, tangential, and he gives answers that are not always relevant to the question. Grooming disheveled. Suicidal ideation: Patient does not answer questions regarding this, but presents after attempting to jump of an overpass.

This evaluation will be different for every patient and the findings aren't always easy to describe, but I find that having a standard framework makes assessment consistent, exponentially easier, and more thorough.

 

Mentioned in this episode

Suicide Risk Assessment master page

Essentials of Emergency Medicine

Mar 01, 2017
Nasal suction. Miraculous simplicity
03:55

It is bronchiolitis season my friends. Even I have a bit of the URI. When we’re talking bronchiolitis, the conversation is almost always about: do steroids or bronchodilators work, what to do with a touch of hypoxia. Important conversations to be sure, but the highest yield pearl I have ever received about bronchiolitis (or any pediatric URI for that matter) was given to me by pediatric emergency physician Andy Sloas. Wash it out, suck it out. 

 

We know that babies are obligate nose breathers. When that nose is plugged, breathing is harder and they don’t eat. When they don’t eat, they get sicker. They cycle continues until they get dehydrated and REALLY sick.

Sometimes a baby with a stuffy nose who isn't eating just needs a little nasal clean out. They breathe easier, they start to eat, or drink (which is usually the case) and often can go home without any other treatment.

So if a child has a URI with a runny nose and isn’t feeding, squirt in some saline and suction out the boogers. The key is in the home care. Most parents will tell you that they’re suctioning with the little bulb suction, but they can benefit from a structured approach.

Home care

How often to suction?

Breakfast, lunch, dinner and right before bed. 

Saline drops

Before suctioning, squirt in some saline drops. You can give the parents some drops or they can buy them from the pharmacy. 

Squirt in the saline drops. The child might cough. They might cough, swallow mucus, and vomit after some saline drops. All that nasal goo getting swallowed can make kids vomit, and that’s expected. Not desirable, but it happens. First saline drops, then suction. The parents might not be able to get mucous with each suction and that’s OK. It’s the repeated attention that matters.

Here is an example of a discharge instruction for runny nose treatment. 

To help clear nasal secretions (nasal mucus and runny nose) spray over-the-counter saline nasal spray (or drops) into each nostril morning and night and with each feeding. After this, suck out each nostril with a bulb suction. Spraying in the saline spray will help clear the nasal mucous and loosen it up so that it can be better suctioned. Your child may gag or cough after the saline is sprayed in the nostrils, this is not unexpected. Keeping your child’s nasal passage open will help them breathe easier and make it easier for them to eat and drink.

 

Disclaimer: This is only an example of phrasing for discharge instructions. It is not meant as medical advice. Please see site disclaimer for further details.

Feb 21, 2017
Articles you need to know - winter edition
27:09

There's a journal club in my living room every few months (or at least there will be - this was the first). Raconteur Adam Rowh, MD joins the show to talk the med lit we dissected by the fireside.
Stuff in this show

  • Prandoni, Paolo, et al. "Prevalence of pulmonary embolism among patients hospitalized for syncope." New England Journal of Medicine 375.16 (2016): 1524-1531. Link
  • Righini, Marc, et al. "Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study." Jama 311.11 (2014): 1117-1124. Link
  • Wang, Ralph C., et al. "Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis." Annals of Emergency Medicine (2016). Link
  • Sakles, John C., et al. "First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department." Academic Emergency Medicine 23.6 (2016): 703-710. Link
  • The Bell Tolls for Renal Colic CT Link
Feb 14, 2017
Mumps
07:21

It's time for a mumps outbreak! Here is a basic primer on the very basic basics.

How do you get mumps? 

  • Respiratory secretions, that guy sitting next to you on the airplane with the huge parotid gland and just sneeze in your eye. Not good.

Incubation period

  • How long does this need to cook before mumps is ready for full star spangled disease manifestation? Somewhere between 2-3 weeks.

Presentation

  • The classic presentation is a swollen parotid gland. Usually it’s both, but in a quarter of patients, it’s unilateral parotitis, which can make things tricky when you’re wondering if this patient has acute bacterial parotitis, or mumps. The other salivary glands can swell as well, but much less commonly than the parotid. 
  • All this salivary swelling business may be preceded by a few days of viral syndrome fever , headache, body aches, feeling crappy.  Patients feel bad for a few days, the parotids swell, stay swollen for anywhere from 2  to 10 days. There may, however, be no parotid swelling as well, just a viral syndrome and nothing else (there may also be no symptoms). 

The other issues with mumps

Orchitis. Can be one testicle, can be  both testicles. Females can also have reproductive organ involvements- less than 1% with oophoritis and a similar rate for mastitis. Non reprotrducgei or salivary gland involvement include aseptic meningitis and pancreatitis.

But wait, I can’t get mumps, I’ve been vaccinated. 

  • Unfortunately that’s not 100% protective and sadly, immunity can wane. 

Treatment

  • There is no specific treatment, just supportive care.

Your job 

  • Your job now is to keep it from spreading. In the hospital, droplet precautions. Mumps is most infectious from 2 days before the parotid swelling to at least 5 days after. Hard to quarantine when there's no parotid swelling, but once it starts, 5 days of no school, no work, and separated from family members (not always possible).

Testing

  • We’re getting these recommendations from the health department to collect samples from almost every body fluid, but isn’t blood enough? It turns out that it is not. Serum IGM, which you’d expect to see in an acute infection, may be falsely negative, especially in someone who has been vaccinated. Many different tissues are infected in mumps, so to really figure out if it’s mumps or not, we’ve been advised to get serum, urine, and buccal swabs. By the time the results come back, your patient will probably be finished with quarantine, but from a public health angle, you’re a hero.

Testing advanced level 

  • In unvaccinated patients, IgM is present by day 5 post onset of symptoms. In a vaccinated person, there might not be any IgM and it could have a very quick spike and disappearance. When you get that IgM mumps test back negative 3 weeks after you’ve seen the patient,  just know that that doesn’t mean they don’t or didn't have mumps. 
  • Why buccal swabs? This tests for the mumps virus itself and is very good in the early stage of infection, especially in someone who has had vaccination, which is hopefully everybody, but it’s not. 
  • Why urine testing? Not as sensitive as buccal testing in early infection but currently recommended in our region. I’m guessing to cast as wide a net as possible. 

Call the health department

  • Initiate patient tracking, contact tracking, and have a public health expert take over with following up on test results etc. 

Bottom Line

  • If you see a patient with parotid swelling and there has been a viral prodrome, or perhaps there’s been a mumps outbreak - think mumps. If you have high suspicion, immediately  initiate droplet precautions, collect samples, call the health department, quarantine (at home) and if possible separate from family for 5 days following onset of parotid swelling. Sometimes that last part is not possible, but have them do their best.

Links

  • Specimen Collection (what to order, exact way to collect it). Link
  • Oregon Public Health Mumps Review (mumps overview). Link
  • Oregon Public Health Mumps Main Page (investigative guidelines, case report form). Link
  • CDC Mumps Pinkbook Review (mumps overview) Link
  • CDC Mumps mainpage Link
  • CDC Current Mumps Outbreaks Link
Feb 02, 2017
Practice Changers
32:08

What were your practice changers in 2016? For me, it was Reuben Strayer's simple phrase for when to give epinephrine in allergic reaction patients: For A, B, or C,  give E. If there is involvement of airway, breathing ,or circulation, give epi. It seems simple when it's spelled out this way, but there can be a lot of hemming and hawing when deciding to give (or not to give) this drug. The other, less clinical, pearl is something learned from former Google engineer Chade-Meng Tang: pick two random people and think, "I hope that person is happy." That's it, just think it, don't have to do anything else. The results are astounding. Now let's hear what our guest panel has to say about what changed their practices in 2016....

 

Simon Carley @EMManchester

 

Michelle Lin @M_Lin

 

Lauren Westafer @LWestafer

  • Elevates the head of the bed to 30-45 degrees when intubating

 

Jeremy Faust @jeremyfaust

  • Recommends E-Cigs as an option for patients trying to quit smoking

 

Jess Mason @Jessmasonmd

 

Al Sacchetti @Sacchettialfred

  • Use ultrasound to confirm foley catheter placement

 

Adam Rowh

  • PATCH Trial
  • Richard Feynman “So my antagonist said, "Is it impossible that there are flying saucers? Can you prove that it's impossible?" "No", I said, "I can't prove it's impossible. It's just very unlikely". At that he said, "You are very unscientific. If you can't prove it impossible then how can you say that it's unlikely?" But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible.”

 

Anand Swaminathan @EMSwami

  • Azithro is losing potency against Strep Pneumo
  • The EKG findings in PE
  • Pre-charge the defibrillator during CPR
  • Use the pelvic binder properly
  • Use the oxygen wave form to confirm pacemaker capture
  • Shared decision making

 

Scott Weingart @emcrit

  • Be careful with hyponatremic patients
Jan 02, 2017
SassyMD
12:50

If you are on Twitter, there's a good chance you've seen commentary from our guest today Sassy MD. She is a 4th year medical student and gives an unfiltered commentary on the trials and tribulations of med school, life, deciding what shoes to wear, and even the internal dialogue about her attendings.

 

In this episode

  • using twitter for mentorship
  • interview advice on how to answer "what is your greatest weakness"
  • integrating 'nontraditional' education into early learning
  • the importance of textbooks
  • the side of emergency medicine you don't learn on rotations (it's the clerical duties!)
  • choosing a specialty
Nov 19, 2016
The Upset Patient Protocol
19:49

We’re not trained in conflict resolution, but angry patients are a reality in any practice. Listening and empathy can go a long way in this situation. Dike Drummond, a.k.a. The Happy MD, give a step by step strategy for engaging with upset patients.

Links mentioned in this show

Link to detailed explanation and video description of the Universal Upset Patient Protocol

Link to Primary Care RAP

Interested in subscribing to Primary Care RAP? Use ERCAST20 to get a 20% off subscription if you're new to the program.

 

Show Notes

Pearls

  • There are 6 steps to the conversation with a patient who is upset.  

    • “You look really upset.”

    • “Tell me about it.”

    • “I’m so sorry this is happening to you.”

    • “What would you like me to do to help you?”

    • “Here’s what I’d like us to do next.”

    • “Thank you for sharing your feelings with me.”

 

  • An encounter with an angry patient is stressful to the overwhelming majority of providers.  It can ruin your day (or days) and that of everyone else in the office.  Medical training does not prepare students to handle these situations.

 

  • The upset patient protocol is a way of structuring a conversation with an upset patient.  It is a doctor-patient communication tool which encourages the patient to share and vent his/her feelings.  After listening to the disgruntled patient, the protocol helps the physician wrap it up so that he/she can proceed with the clinical part of the office visit.  This protocol works about 85% of the time with angry patients, regardless of the source of the upset.  The remaining 15% will stay upset despite your best efforts to placate them.

 
  • Step 1:  Notice the patient is upset.  

    • Take a deep breath, get present, and make sure that you are centered when you walk in the room.  If you do not notice that a patient is upset, he/she will get even more angry, assuming that you don’t care or that you’re clueless.

    • Sit down.

    • Show that you recognize the patient is upset by saying, “You seem upset.”

 
  • Step 2:  Invite the patient to talk about it.

    • Give the patient permission to tell you about their frustration by saying, “Tell me about it.  Tell me what happened.”

    • Let the patient speak or vent frustration without interruption.  Refrain from being defensive.

    • Breathe and remember Theodore Roosevelt’s phrase:  “They don’t care how much you know until they know how much you care.”   

 

  • Step 3:  Show empathy for the patient’s situation and apologize.

    • You can be sorry for the way the patient feels or for his/her experience without apologizing for anything that you have done.

    • Say something like,  “Wow.  I’m so sorry that you’re feeling this way.  That sounds so frustrating.  I’m so sorry this is happening to you.”

 

  • Step 4:  Find out what’s their agenda.  

    • Ask the patient, “What would you like me to do to help you?”  

    • Sometimes the patient will say, “I just need you to listen.  I needed to tell somebody.”  Other times the patient will ask for something specific, which may or may not be reasonable.  If unreasonable, the provider needs to set boundaries around the relationship and decide what he/she is willing to do.

 

  • Step 5:  Determine what you’re willing to do to address the patient’s concerns.

    • “Here’s what I’d like us to do next.”

    • If the patient requests something ridiculous (such as “Give me $10,000”), it is important to not laugh, get upset, or roll your eyes.  Respond with, “I can understand how you feel.  I’m not willing to do that.  You know that, right?  Here’s what I am willing to do.”  And then you tell them what you’re willing to do.

    • Emphasize what you’re going to do, and not what you’re not willing to do.  The negotiation should be very quick and, typically, you’re right back on track with their frustration diffused.

    • Usually, if you’ve listened to the patient and shown them how much you care, they’ll make a very reasonable request and something that is potentially within your power.

    • Once physicians inform patients about what they’re willing to do within the boundaries of good medicine, patients can then decide whether they want you to continue to be their doctor.  Never put yourself in a position with an upset patient where you feel you’re in danger.  For instance, never prescribe narcotics that you think are inappropriate.  Let the patient know that they’re perfectly capable of seeking a separate medical opinion from another doctor.

 

  • Step 6:  Thank the patient for sharing his/her feelings and trusting your relationship.

    • “Thank you so much for sharing your feelings with me.  It’s really important that we understand each other completely.”

  • The Universal Upset Patient Protocol does not work on 15% of patients.  Nothing works universally, and some patients will remain angry no matter what you say.

  • Everyone in the clinic or office should be trained in the Universal Upset Patient Protocol.  Oftentimes, a receptionist or nurse can placate the patient so that the physician can focus on the medical issues that brought the patient to the office in the first place.  Ideally, physicians and other staff members should rehearse and practice these conversations, so that they are comfortable using these tools when an upset patient walks in the door.

Sep 28, 2016
The Stroke Consult
15:03

When you are calling a consultant, whatever the specialty, what are you really doing? You are presenting an argument, making a case for what you think should be done, or making the best case for what you think is going on and seeking the benefit of their expertise. One area where this gets a little short circuited is in the acute stroke consult. The short circuit has its roots in the early days of TPA in stroke literature. When the NINDS study came out, my neurologist friends were beyond belief excited. Finally a therapy for stroke! 

At the same time, there was a counter argument. The legendary emergency physician and skeptic, Jerry Hoffman, said, "This data does not support using thrombolytics in stroke, in fact quite the opposite." Therein began the divide that has only grown since and therein began the stroke treatment narratives within neurology and emergency medicine.  For the most part, neurologists favor TPA and many ED docs do not. We read the same studies, all went to medical school and want the best for our patients. I’m not going to debate the merits and dangers of TPA here. I bring this up because this dichotomy leads to stress at the wrong time.

The decision of whether or not lytics are going to be part of your stroke practice needs to be decided before you see an acute stroke patient. Once you make that consult, you are already on the path of potentially giving lytics and if you are going to do it, you should do it it the most expeditious way possible. Not that you can’t advocate for the patient, because you absolutely should. So when you call the neurologist for a patient with an acute stroke stroke patient, be professional and be economical with the presentation, no BS and no unneeded information.

Elements of a Stroke Consult

  • Age
  • Last normal
  • Onset of symptoms and type of symptoms if witnessed
  • Blood sugar
  • Are they on anticoagulants
  • What is the blood pressure
  • NIH stroke score and specific deficits that gave the patient points
  • Where is the patient is on their path to CT

 

 

Now, the consult. This is not a full chitty chat long form conversation, this is a condensed bolus of vital information. 

  • This is a 70 year old male, last seen normal at 9am. At 10 am, family heard some noise in the living room and found the patient stumbling around, weak on the left side. Paramedic blood sugar was 100, normal. Patient is on aspirin but not anticoagulants. Last blood pressure 200/100. Eam shows an NIH stroke score of 6. All points are given for left sided weakness. There is a partial left  facial palsy, left arm and leg cannot resist gravity. We are now 90 minutes after last seen normal and the patient is being packaged for a stat CT.

Done

There will be questions after this, there always are. You have the benefit of a tremendous amount of information: you’ve met the family , shared the same air as the patient, your consultant is only getting the picture you’re painting. There will be talk of heart rhythm, comorbidities, potential exclusion criteria. etc. But that is the initial call. Short, sweet and to the point. 

 

NIH Stroke score training video

Sep 23, 2016
Airway Strategery
27:46

Scott Weingart from EMCRIT guest stars in this episode to discuss his approach to two challenging airway cases. The common theme is ketamine and semi-awake intubation (or at least maintaining breathing while inserting the laryngoscope).

Mentioned in this episode

Rapid sequence awake intubation

Rapid Sequence Awake Intubation by EMCRIT

Use something like the EZ-Atomizer - Jet sprayer to administer lidocaine in rapid sequence awake intubation. About 12cc of 4% lidocaine jetted all around the back of the tongue, throat, direct the tip to the cords and epiglottis

2% or 5% topical lidocaine to the back of the tongue with a tongue depressor. It'll slip down the back of the tongue into all the nooks and crannies

Cords not opening during an awake intubation? Try a small dose of propofol to relax the patient and abduct the cords.

Post intubation sedation. Be generous with analgesia and sedation. Rob prefers fentanyl bolus and drip, propofol bolus and drip. If a fentanyl drip isn't readily available, Scott recommends using hydromorphone 1mg IV and then scheduled hypdromorphone in addition to propofol.

Pocket Bougie

Glidescope titanium

Jess Mason's rapid sequence awake intubation narrative learning segment from EM:RAP

Books Scott and Rob are reading

When Breath Becomes Air

A Strange Relativity. Beautiful video done by Stanford University about When Breath Becomes Air author Pail Kalithini

Sapiens

Surrender New York

The War of Art

The Art of Learning

The Slow Regard of Silent Things

Strategery

Strategery

Sep 03, 2016
Mastering the storm
38:21

Intro: Scott Weingart explains why he meditates and how it's like 'kettlebells for the brain'.

Main episode: Chris Hicks is a Canadian emergency physician and trauma team leader. In this episode, he gives simple practices to improve your management of an emergency department shift as well as controlling the resuscitation room in a calm, effective manner.

 

Follow us on twitter

Mentioned in this episode

Jul 12, 2016
Angioedema
18:01

Does anything work to reverse angioedema? If it's hereditary, then icatibant may do the trick. Otherwise, there's not much out there. Fresh frozen plasma (FFP) has it's place in angioedema lore as something that works, but the evidence in its favor is a series of case reports. Emergency physician and angioedema researcher Gentry Wilkerson gives a State of the Union on the known knowns and known unknowns of this sometimes mysterious disease.

Links mentioned in this show

Register for Essentials of Emergency Medicine

Angioedema algorithms

Cicardi, Marco, et al. "Guidance for diagnosis and treatment of acute angioedema in the emergency department: consensus statement by a panel of Italian experts." Internal and emergency medicine 9.1 (2014): 85-92. Link

Bowen, Tom, et al. "2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema." Allergy, Asthma & Clinical Immunology 6.1 (2010): 1-13. Link

Chiu, Alexander G., et al. "Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management." Annals of Otology, Rhinology & Laryngology 110.9 (2001): 834-840. Link

Hassen, Getaw Worku, et al. "Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema." The Journal of emergency medicine 44.4 (2013): 764-772. Link

May 01, 2016
REBOA 101
29:47

Are you ready for REBOA? Zaf Qasim (@emeddoc) gives the ins and outs of Resusciataitve Endovascular Balloon Occlusion of the Aorta

Intro Segment:
Mel Herbert and I talk about our favorite podcasts as well as Mel's new show Shabam!

My Top 3: The Tim Ferriss ShowQuestion of the DayMen In Blazers

Mel's Top 5: Radiolab99% InvisibleCommon SenseMemory PalaceMacbreak Weekly

Episode Transcript (with some extras)

What are the steps of REBOA?

To understand REBOA you have to know a little bit of anatomy.  We talk about 3 aortic zones when we talk about REBOA.  Zone 1 is from the left subclavian artery to the celiac trunk, Zone 3 is from the lowest renal artery to the aortic bifurcation, and Zone 2 is the area in between.  We don’t like to talk about zone 2 – that’s essentially a no go zone because if you inflate the balloon here, you may not occlude the vessel that’s causing the bleeding.

So once you’ve decided to place REBOA, and we’ll talk about indications and contraindications a bit more in a second, the key step is accessing the common femoral artery and putting in a standard 18G arterial line.  Next, you’re going to be passing a long guidewire through that arterial line up to the level of the left subclavian.  We use a stiff, 260cm wire to do this, and measure it using external landmarks.  If you have the time, you’ll get a chest xray to confirm the position.  Next, you’ll replace the arterial line with an introducer sheath – the one we use is actually pretty huge, 12 French, and that allows passage of the actual balloon catheter.  You’ll need to measure the length of insertion against your external landmarks, and that’s the xiphisternum for Zone 1, and the umbilicus for Zone 3, pass the catheter over the wire through the sheath, and inflate the balloon with saline in the appropriate zone until you feel a change in resistance as the balloon abuts the aortic wall.  You should at this time see a pretty dramatic rise in your blood pressure.

Who gets this? Pelvic fractures, get that, but I’m hearing about it in any sort of hemorrhagic shock, sort of a poor man’s cross clamping of the thoracic aorta without having to crack the chest

So yeah, you hit the nail on the head – this is the alternative to cracking open the chest and putting a big clamp on the aorta just for the purposes of stopping bleeding below the diaphragm and improving cardio-cerebral perfusion.

Let’s talk first about who’s not going to get it.  If you think your patient has some sort of horrible chest injury, like a cardiac tamponade or a traumatic proximal aortic dissection, you do NOT want to put a balloon up there. That’s just going to make that patient’s day a whole lot worse.  You can easily rule those things out with what you do already in the trauma bay, the FAST and the chest xray.  If you see a tamponade, you’re going to be opening the chest.

But if you think this patient has what’s termed non-compressible torso hemorrhage, that is, devastating bleeding from areas below the diaphragm in the abdomen, pelvis, or retroperitoneum, places you can’t put a tourniquet or direct pressure to, these are the folks who will benefit from REBOA.  This can be from blunt or penetrating trauma, and even non-traumatic hemorrhage as I’ll talk about in a second.  If you’re suspecting abdominal bleeding, they’ll get a Zone 1 balloon, for pelvic bleeding it’s Zone 3.

The beauty of this procedure is that you don’t have to wait for the patient to die before you proceed like you do with the thoracotomy.  You can proactively place this in the transient or non-responder.  Since you’re being proactive about this and stemming bleeding before the patient undergoes that horrendous insult called death, I think you have the potential to have a higher percentage of what you really want at the end of this - neurologically intact survivors, and this is what we’re already seeing.

At Shock Trauma we’ve also placed REBOA in witnessed traumatic cardiac arrest, but I think you really need to have witnessed that arrest for this to be a useful procedure.

People wonder how long this procedure takes to do what with all the wire and device changes that are occurring.  The answer, and we have this data from the interim analysis of an ongoing national study called AORTA, is that it is not statistically different to the time it takes to do a thoracotomy and get an aortic cross-clamp on right.  This really annoys the naysayers!

Remember, before you do this you’ll already have gotten your IV access, started your damage control resuscitation, placed the pelvic binder, done all that.  If they’re STILL circling the drain, so the transient or non-responder, and you think they’re highly likely to code, REBOA is the next step to buy them those precious minutes to get to the OR or in some cases to IR.  But don’t forget the basics!

 

What would it take for me to go from where I am today, a true neophyte, to REBOA operator?

I think as with any new procedure it’s critical that people get the right training to do this, as it is certainly not without risk.  Having said that, REBOA builds on skills that emergency physicians already have – the use of ultrasound to localize the common femoral artery and the use of a Seldinger technique to insert the various pieces of equipment.

Essentially the first critical step, placing the femoral arterial line, is something we have been trained to do.  The caveat is you have to be sure you’re in the common femoral artery.  It’s always a little higher than you think it will be, but with dynamic ultrasound, you can be trained to do that safely and efficiently.  My advice is place that arterial line in your sick patient early, while you still have a decent caliber vessel to access.  If they get better, hey you’ve got a central arterial line.  If not, though, you’ve already done the rate-limiting step of the procedure.

Upsizing to the 12 French sheath can be daunting – think of your usual Cordis (or introducer) but on steroids! You have to be very careful to ensure you’re inserting this without feeling any major resistance, and that your dilator doesn’t inadvertently get pushed out as you’re putting the sheath in.  But again this step builds on principles we as EPs already have.

In the US, this technique was trialed and brought out primarily by trauma surgeons, and the reason behind that was not only the way trauma care is delivered in the US but also the high potential for injury when you stick a huge sheath into the femoral artery.  Additionally, you can’t just pull that thing out at the end of the day, get the medical student to hold pressure, and go get some coffee.  No.  It needs a formal assessment and closure of the hole made in the artery as well as ensuring good limb perfusion at the end of the procedure, and that’s a skillset we as emergency physicians don’t have.  You may also need to perform a cutdown on the groin to access the artery, especially in the setting of cardiac arrest, and that’s a skill we don’t have from our training but one that CAN be learnt.

So on the back of that, the initial training courses that came out here were really also directed at the surgeons, and there were initially two in the country.  I teach one of them, the Basic Endovascular Skills for Trauma course down in Baltimore, and our candidates are primarily surgeons.  We do both simulator and cadaver work with them.  Currently the only EPs that have been trained on our course are those with dual training in critical care and affiliated with Shock Trauma.

But this will evolve and change for two reasons I think.  First, emergency physicians have already demonstrated that, with appropriate training, they can safely and effectively perform procedures with big catheters like ECMO – just look at the Reanimate course and the work out of Sharp Memorial in San Diego.  Second, and this is the most exciting news, back in October, the FDA approved a new, purpose built device called the ER-REBOA catheter (and I have no financial interest in this device by the way).  This can be placed through a much smaller 7-French sheath – that’s the size of the Cordis we all know and love.  Additionally, there’s no lengthy wire that needs to be put in before hand, you can just do your measurements using this catheter device and place it in the appropriate zone.

So to summarize, yes, emergency physicians can build on their existing skillset to learn this procedure, and with appropriate training and within a system of robust quality assurance, will be able to safely deliver this.

 

Is this ready for the community ED?

That’s a great question.  It’s certainly a very attention-grabbing procedure that’s in the headlines and I think ultimately this will have a key role in the community ED.  You’re essentially aiming to extend your golden hour by placing this.  Imagine you’re at a single coverage community ED and you get an unexpected drop-off who is a bad motorcycle victim who’s bleeding out from his abdomen or pelvis, you place this device, get control, and are able to ship them off to the regional level 1.  Not only that but think of the patient with a non-traumatic bleed, a ruptured ectopic for example – the same principle applies and you can use REBOA to buy them time for either your own surgeon to come into the hospital or to get them out to your local ivory tower.  That is the ultimate goal.

Are we there yet?  I think not quite.  Currently as you say REBOA is being performed at big academic centers, like the intergalactic shock trauma center.  These places are able to get the patient to the OR fairly quickly and have the complement of specialties in house or very rapidly accessible to deal with any issues or complications that may arise as a result of placing REBOA.  There are some issues that still need to be worked out before we’re ready to say that community docs within a trauma network will be able to utilize this technology.  These are primarily centered on training and system logistics.  But I think one of the major limitations is time.

 

What’s the treatment arc of REBOA? How long can it stay in? What should be your mindset once you place it?

The mindset once you put in REBOA is “I need to get this person to definitive care as soon as humanly possible.”  These aren’t people who will tolerate you scratching your head or rubbing your chin. They’re staring you down and saying “I’m sick as hell, fix me” Once the balloon is up you need to already have a plan in place of how you’re going to fix the problem.  You may have some time depending on how your shop is set up to get some focused imaging, but the default destination is most likely going to be the OR.  That highlights a couple of things.

First of all, you need to limit balloon inflation time.  Think about it, if you’re putting a balloon in Zone 1 and occluding flow to everything below the diaphragm, you’re taking out a lot of real estate – the kidneys, the gut, even the spinal cord.  Your patient is not going to like that.  The animal studies and the limited human studies show elevations in lactate proportional to the duration of balloon inflation.  The animal studies show that up until about the 40-60-minute mark, appropriate resuscitation will clear that lactate, but beyond that it can precipitate a devastating cycle of physiologic injury that you may not recover from.  On top of that, when you let the balloon down after prolonged inflation, you run the risk of reperfusion injury – akin to those people you treat with crush syndrome.  Zone 3 balloons are a bit better tolerated but still have the same principle to them.

The Japanese papers really highlighted this.  They have been doing REBOA much longer than we have, and their papers were showing complications not clearly evident in our limited US data.  Their system is somewhat different: they don’t see a lot of trauma and so their surgeons aren’t in house.  Their EPs are trained to put in REBOA and call the surgeon in.  Because of this their time to get to the OR may average well over an hour, and that was one reason I think those patients were having less than optimum outcomes.  The other being they sometimes resorted to using the balloon as a last-ditch, throwing the kitchen sink at the problem effort.  So it goes to further emphasize the timing issue – if you’re going to use it, use it early, and then get them to definitive care quickly.

The second thing this highlights is if you’re thinking of bringing this into your service, you need to train your team to hustle efficiently once the procedure is performed.  There can’t be delays because of rubbernecking or high-fives that you’ve done this sexy new procedure – do that after you’ve fixed the problem for sure, but not at the time.  Remember if you’re the one doing the procedure, you put on blinders and become task-focused.  You develop tunnel vision and lose that situational awareness.  This patient is still extremely sick, and so needs ongoing resuscitation.  You need to designate someone to take over and lead the resuscitation so that the blood products still go in, the right services are involved, and the team is coordinated to move this patient to the OR once the balloon has gone up.

The way I wrote the protocol at our shop for example is that in our trauma codes, the trauma surgeon will move from supporting the senior trauma resident as the team leader to becoming the proceduralist.  The emergency physician moves from supporting the airway resident at the top of the bed to becoming the designated team leader and the direct support for the trauma resident.  Our nurses help by clearly documenting times of balloon inflation.  In the OR, the anesthesiologist with help from the circulating nurse becomes tasked with reminding the surgeon using closed-loop communication about the duration of balloon inflation so that everyone is geared to limit that time the balloon is up.  That requires team training beyond just learning the procedural steps.

 

This has all been pixie dust and fairy parties so far, but what are the downsides of this procedure?

What’s wrong with fairy parties?!  Definitely nothing comes for free though.  We already spoke about the big issue of the physiologic consequences of balloon inflation, so keep an eye on those times.  There’s the risk of losing situational awareness which we also touched on.

Additionally, you always run the risk of vascular injury – you can put the sheath into one of the smaller branch vessels and risk shearing that off, or creating dissection flaps.  You might access the vein by mistake, guaranteed not to get you any style points.  The balloon may inadvertently migrate, or potentially fail.

But a really huge issue is the risk of critical limb ischemia and limb loss.  There are reports from abroad of this having happened, and to date, the US has not had any reported cases of limb loss.  The limb is at risk for a variety of reasons – the size of the sheath can completely occlude the main vessel to the leg, especially in smaller patients.  Also, and you wouldn’t have thought this would happen in people who are so sick, is that our surgeons are often seeing clot around the sheath at the time of removal and vessel repair, which sets it right up for ischemic and embolic problems.  I think one of the inadvertent benefits of needing to use a huge sheath currently in this country is that it dictates open repair and removal.  So the surgeons have the opportunity to check limb perfusion right there in the OR at the end of the case and make sure the flow is appropriate, and I think that’s why we don’t have any reported US cases of limb loss from the use of REBOA.  Be extra vigilant about limb perfusion – ANY difference between the two limbs, even a slightly different color, mandates vascular to come and assess that leg again.

A final point which isn’t exactly a complication but should be mentioned is the notion that REBOA is either not something worth doing or might be done for the wrong reasons and so more often than indicated.  There are certainly naysayers, and yes it’s new and still being tested but it is already showing positive results and importantly has the benefit of producing neurologically intact survivors.  It can certainly be incorporated as another tool in the box in managing these difficult patients in an attempt to get them to definitive care.  On the other hand, new toys might get used when they shouldn’t be or in lieu of good basic tenets of trauma care.  So to ameliorate that effect, bring it in within a strict protocol that undergoes a strict QA process – do it right and remember your basics.

Say I have a patient with a crushed pelvis, I put in a REBOA, is that patient OK for transfer to a bigger trauma center? Is bad pelvic fx in any way a contraindication?

Bleeding pelvic fractures are the ideal candidates to get a Zone 3 REBOA and be moved to the trauma center.  Remember you should also put on the pelvic binder and continue your usual resuscitation but these are the guys who have a high mortality in the civilian literature. They will bleed out quickly-  talk and die.  The zone 3 position may also tolerate slightly longer balloon inflation times than zone 1.

 

What are your take home points?

REBOA is a promising procedure for managing devastating torso hemorrhage

The skills for it build on those that we as emergency physicians already have, but need to be refined through specific training and need to be delivered within a multidisciplinary system having a robust QA process

Balloon inflation times and the potential for limb ischemia are very real threats to its use

Both the technology and the data continue to evolve, so collaborate, share your experience, and watch this space

 

Reference

Qasim, Zaffer, et al. "Resuscitative endovascular balloon occlusion of the aorta." Resuscitation 96 (2015): 275-279.

 

Mar 20, 2016