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ERcast

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Education
Self-Improvement
Health & Fitness
Medicine
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A short, focused discussion of emergency medicine topics with perspectives from emergency physicians as well as other specialties. Here's the problem: When I listen to a 45 minute lecture that goes through about 15 different studies and has 50 slides, I come out feeling like a genius. An hour later, I have forgotten 95% of it. Here's the solution: ercast. We cover a single issue and try to tease out all the relevant elements without overstuffing your frontal cortex. It's for physicians and anyone interested in a bare bones look at emergency care.

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A short, focused discussion of emergency medicine topics with perspectives from emergency physicians as well as other specialties. Here's the problem: When I listen to a 45 minute lecture that goes through about 15 different studies and has 50 slides, I come out feeling like a genius. An hour later, I have forgotten 95% of it. Here's the solution: ercast. We cover a single issue and try to tease out all the relevant elements without overstuffing your frontal cortex. It's for physicians and anyone interested in a bare bones look at emergency care.

iTunes Ratings

385 Ratings
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359
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5

ūüĎć

By ati90116 - Dec 07 2018
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Plz use number for episodes ūüôŹ

Great!

By hosehead1423 - Feb 13 2016
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Sad to see the episodes stopping though

iTunes Ratings

385 Ratings
Average Ratings
359
12
6
3
5

ūüĎć

By ati90116 - Dec 07 2018
Read more
Plz use number for episodes ūüôŹ

Great!

By hosehead1423 - Feb 13 2016
Read more
Sad to see the episodes stopping though

Listen to:

Cover image of ERcast

ERcast

Updated 3 days ago

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A short, focused discussion of emergency medicine topics with perspectives from emergency physicians as well as other specialties. Here's the problem: When I listen to a 45 minute lecture that goes through about 15 different studies and has 50 slides, I come out feeling like a genius. An hour later, I have forgotten 95% of it. Here's the solution: ercast. We cover a single issue and try to tease out all the relevant elements without overstuffing your frontal cortex. It's for physicians and anyone interested in a bare bones look at emergency care.

How to master CPR

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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‚Äôs right side and new compressor comes in from the previous compressors right side.¬† Opposite is true for left sided compressions.
  • New compressor to ‚Äúhover‚ÄĚ 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 ¬Ĺ 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, ‚Äúdump‚ÄĚ 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 ‚Äúsimultaneously‚ÄĚ 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

41mins

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ZDoggMD

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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¬†‚ÄĒ¬†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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Or hereto sign up and skip the details

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

44mins

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Massive GI Bleed on Anticoagulants

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

May 04 2018

30mins

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Alcohol, c-spines, and lots of pus

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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‚Äôt 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, p12hrs) 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

43mins

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How to Use the Pulse Ox Like a Boss

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From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.

Pearls:

  • The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.

  • For patients ¬†breathing room air, pulse oximetry can be used to monitor for hypoventilation. ¬†
  • Nail polish has minimal impact on the accuracy of pulse oximetry.
  • If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.

  • ‚ÄúThe respiratory rate is the most vital of the vital signs.‚ÄĚ ¬†¬†¬†Experienced doctors look at a patient who seems well, but understands that they‚Äôre not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately. ¬†Since we don‚Äôt always have access to reliable respiratory rate, Strayer‚Äôs go-to vital sign is the oxygen saturation.
  • ‚ÄúReusable pulse oximeter probes are gross.‚ÄĚ ¬†One study found that even when these probes are cleaned by standard procedure, ‚ÖĒ had bacteria cultured from them. Strayer recommends using single use probes in your department.
  • Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923.
  • Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal. ¬†
  • Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect. ¬†
  • If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger.
  • Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149.
  • As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.

  • Significantly hypercapnic patients saturate less than 95% when they‚Äôre breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing.
  • If you need to give supplemental oxygen, then use capnography to monitor respirations.

  • The pulse oximeter does so much more than provide oxygen saturation. ¬†

  • It provides the photoplethysmogram (PPG) which is a waveform that tells you the ‚Äúmechanical‚ÄĚ heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.

  • The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high). ¬†The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF.
  • Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670.
  • van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972.
  • What if you don‚Äôt have a reliable pulse ox tracing?

  • Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there‚Äôs a lot of ambient light.
  • If you‚Äôve corrected for these problems and you still don‚Äôt have a good tracing, you should be concerned that the patient is poorly perfused.
  • One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status. ¬†
    • Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.

  • How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?

  • One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin. ¬†
  • The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning.
  • The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead.
  • Functionally, ¬†it doesn‚Äôt seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger. ¬†For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.

  • Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891
  • Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826

  • DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link.
  • Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227

Mar 11 2019

20mins

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Why Epi Might (and might not) Work in Cardiac Arrest

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The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.  

20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed.  Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission.

Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate.  Also, amongst the survivors, the neurologic outcome was worse.

Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful.

The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period.  These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.

Jul 01 2018

22mins

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Acute MI in Cardiogenic Shock with Weingart and Mattu

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Scott Weingart and Amal Mattu are our guests as we break down the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.

Want weekly episodes, world class show notes, CME, and a super sweet app? Go to ercast.org and subscribe to the kit and caboodle.

Jul 06 2019

39mins

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Cellulitis

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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‚Äôs 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‚Äôt, 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

17mins

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The White Coat Investor

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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

1hr 2mins

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Mind of an Addict

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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

22mins

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Internal Medicine in the Emergency Department

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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

25mins

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When can you shower after stitches?

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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‚Äôre wondering if that injured tendon needs repair, if it‚Äôs 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‚Äźoperative 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‚Äźtissue 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‚Äď2008."¬†Dermatitis24.1 (2013): 10-21¬†PMID:¬†23340394
  2. Common contact allergens explained The Dermatologist 2014

Nov 27 2017

14mins

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Haloperidol for Analgesia

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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 link.¬†PMID:¬†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. ‚ÄúHaloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.‚Ä̬†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

25mins

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Evidence Based Hyperkalemia Management

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Hyperkalemia is one of, if not the most, common electrolyte abnormalities we see. But much of what we do in treatment is what someone told us to do when we were young learners. In this episode we debunk hyperkalemia myths and discuss an evidence based approach to management. For more great content check out 

https://www.hippoed.com/em/ercast/

Nov 07 2018

34mins

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Pseudoseizures (PNES)

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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 ‚Äėfaking it‚Äô?
  • 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 ‚Äėfaking it‚Äô 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‚Äôve 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‚Äôt pause and then restart, a pause favors PNES
  • Flailing. You‚Äôd think the flailing patient has PNES for sure because epilepsy doesn‚Äôt flail, but it does! Flailing is much more common in PNES, but not so much so that it‚Äôs 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‚Äôt ‚Äėfaking it‚Äô
  • 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

15mins

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Infected and Obstructing Nephrolithiasis

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Patients with infected ureteral stones present a true medical emergency. I very well may be obvious what's going on but, often, it's not so clear. Maybe the patient has no fever but a few white cells in the urine, or maybe they look sick but have a negative UA. In this wide-ranging discussion, we interview urologist Nora Takla about her approach to infected stones, how she manages those with equivocal presentations, as well as the logistics following up non-infected stones, the significance of extravasation on CT scan, and the sometimes surprisingly complicated decision making when it comes to admitting ureteral colic patients.

Subscribe and hear the rest of the show.  CLICK HERE! For access to more incredible education and 2.25 hours of CME each month. 

Apr 13 2019

33mins

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Should I give bicarbonate in DKA?

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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‚Äôt 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

Jan 15 2018

19mins

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The Dying Asthmatic

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  • Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy.¬†¬†Asthma is different than other causes of severe respiratory distress. ¬†And there are different forms of asthma as well.

  • Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case?

    • Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management.

    • In the rare cases of severe asthma with a ‚Äėstone chest‚Äô that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible. ¬†It‚Äôs the only way to safely provide the airway pressures you need.

      • Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration.

      • Failed attempts at intubation are especially risky in these patients. ¬†As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.

Aug 06 2018

31mins

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Emergency Complications of Cirrhosis

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Britt Long, MD and Rob Orman, MD discuss emergency department management of patients with complications of cirrhosis.

Sep 04 2018

30mins

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C Diff Treatment Changes

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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 ‚ȧ 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

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

‚ÄĘ 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‚Äď14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2‚Äď8 weeks), OR

‚ÄĘ ¬†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‚ÄĒassociated 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‚Äďassociated 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

12mins

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Aim To Be a Zero

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What does emergency medicine have in common with astronautics? A lot, it turns out. Dan Mccollum and Rob break down the skills learned by International Space Station commander Chris Hadfield as explained in his autobiography An Astronaut's Guide to Life on Earth.

 

Become a Full Member of ERcast Here

Pearls:

  • You can be a ‚Äúplus one‚ÄĚ -- someone who actively adds value -- without behaving like an arrogant person craving significance.

  • Avoid trying to impress others by showing off.

  • We learn much through adversity, when things don‚Äôt go well.

  • What we say matters. Critique a behavior, not a person.

  • The pitfalls of thinking too highly of yourself. ¬†[1:48]

  • On the importance of being a ‚Äúplus one‚ÄĚ and the wisdom of not proclaiming your plus-oneness. ¬†‚ÄúIf you‚Äôre really a plus one, people will notice‚ÄĚ. [2:25]

  • Aim to be a zero -- having neutral impact. ¬†Observe and learn. Pitch in with the grunt work. Being a zero is a good way to get to plus one.[5:10]

  • What Mccollum looks for in EM residency applicants: ¬†people who treat the receptionist or program administrator well. [8:02]

  • Focus on the simple core things which are most likely to save lives, as opposed to shooting for the stars with cutting edge treatment. ¬†[8:50]

  • On why the weight and power of ego impairs our ability to learn and harms patients. [11:04]

  • Sweat the small stuff. [13:03]

  • The quintessential nature of EM and how they‚Äôre similar to flight rules: ¬†solving complex problems rapidly with incomplete information. ¬†[13:51]

  • Why we should be using checklists, particularly when we think we don‚Äôt have time for them. [14:49]

  • Even when you follow all the rules, sometimes bad things happen. Perfectionism is not part of the flight rules. [15:51]

  • Why early success is a terrible teacher. ¬†If you‚Äôve always been the star and never experienced failure, this can be a barrier to learning. [18:29]

  • Jocko Willink video,¬†Good.¬†When bad things happen and you get knocked down, ‚Äúget up, dust off, reload, recalibrate, re-engage, and go out on the attack‚ÄĚ. [20:15]

  • When in a position of leadership, be careful with your words. ¬†Don‚Äôt ridicule. The small things we do or say can have a big impact. [22:02]

  • Expeditionary behavior is the willingness to endure hardships for the sake of the mission. And why whining poisons the pool. ¬†[24:15]

References:

An Astronaut's Guide to Life on Earth by Chris Hadfield

Nov 30 2019

30mins

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ERcast/Essentials of Emergency Medicine 2020 - Fellowship Competition

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The Essentials of Emergency Medicine (EEM) conference is in May 2020, but opportunities start NOW. This conference is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are again offering an amazing opportunity for EM residents anywhere in the world to serve as an EEM Fellow for the next EEM conference May 21-23, 2020.

APPLY NOW: ERcast’s 2020 Audio Podcast Competition for Essentials of Emergency Medicine Education Fellowship Program 

The Essentials of Emergency Medicine (EEM) conference is in May 2020, but opportunities start NOW. This conference is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are again offering an amazing opportunity for EM residents anywhere in the world to serve as an EEM Fellow for the next EEM conference May 21-23, 2020.

EEM Education Fellowship

EEM is offering ERcast a mini-fellowship position to eligible residents anywhere in the world. Those selected to participate will receive:

  • FREE conference registration

  • FREE 4-night hotel stay at the Hilton Union Square, San Francisco, CA

  • A travel stipend of US $500

As part of the EEM staff, fellows will get a rare opportunity to experience the behind-the-scenes work associated with developing and producing one of the world’s largest and best EM educational conferences. Fellow responsibilities will include online chat moderation, social media management, CME preparation, research projects, and more. A common theme voiced by previous EEM fellows has been the opportunity to interact directly and develop meaningful relationships with the renowned, fun, and master clinician-educators in the EEM faculty.

Quotes from the 2019 EEM Fellows:

‚ÄúThis fellowship was more than just a chance to attend and work at a phenomenal educational conference. It gave me the opportunity to meet and work alongside other amazing residents and faculty that I don't think I would have crossed paths with this early in my career otherwise. What this fellowship really played out to be though was an invaluable networking opportunity with giants in the field of Emergency Medicine. I established mentors, I curated friendships and most importantly, changed my mindset of what medical education has to look like in the absolute best way possible. Not only would I work this conference again and again, I will be in attendance for it every year I can be. Paul and his team changed the game of what traditional ‚Äėcontinuing medical education‚Äô has to look like and it was a privilege to sit front row to witness and learn from it.‚Ä̬†-Michelle Romeo, MD

‚ÄúWithout a doubt, the most fun you‚Äôll have at a conference, ever. EEM is what all conferences should be- high-yield, exciting, fun, pinpoint educational pearls with a one-of-a-kind ambiance of comradery, fellowship, and shared experience... Essentials is truly something very special. It is hard to explain to my friends how exciting, educational, AND entertaining this conference is! I returned to my work with a renewed love for my specialty, my patients, and my colleagues. See you next year!‚Ä̬†‚ÄďTim Montrief, MD, MPH

Application Process

We at ERcast are launching this contest for interested applicants in conjunction with Dr. Michelle Lin at ALiEM. What’s the primary difference between the two contests? ERcast’s contest involves creating an audio podcast submission while ALiEM’s contest involves writing a blog post.

Complete the application form below and submit a 1-minute audio submission on anything clinically or educationally relevant to EM providers. Be creative, showcase your educational prowess, and teach us something about a topic you are passionate about! 

All applicants must be in good standing at an ACGME-accredited Emergency Medicine program in the United States, or in good academic standing at any Emergency Medicine residency program in the world, and be available to attend all 3 conference days of Essentials of EM in San Francisco May 21-23, 2020. Applicants should complete a brief online application and upload material through the online form below. The application process is open now.

Judging Criteria

Your audio submission (< 60 seconds) will be judged on:

  1. Relevance (How relevant is this submission to EM education and/or clinical practice?)

  2. Innovation (How creative and innovative is this submission?)

  3. Design (How well is the information presented and delivered?)

  4. Content (How well did this candidate present the material with respect to clarity, conciseness, accuracy, references?)

Important Dates

  • Deadline for submissions:¬†January 15, 2020¬†at 11:59 pm PST

  • Fellowship winner announcement:¬†January 31, 2020

Questions? Email us.

Ready to Submit Your Application?

Checklist:

  1. Your post-graduate year of training

  2. Your EM residency program name, program director’s name, and his/her email 

  3. Your email address

  4. Your audio file (please submit in mp3, m4a, or wav format) 

Go to Application Submission Site

Nov 06 2019

4mins

Play

The False Assumption of Admitting Errors

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Should we admit medical mistakes? Most risk managers (and med mal attorneys) might say no, but Dr. Peter Smulowitz says that’s the wrong thinking. Admitting errors can be good for patients and good for us.

Links mentioned in this episode

Shownotes

Pearls:

  • The victims of our current risk-management strategy (which is to pretend it didn‚Äôt happen, and, if discovered, to deny and defend) are the patient, the provider, and the system.¬†

  • Communication, Apology, and Resolution (CARe) programs have been developed to encourage providers to talk about adverse events and create a transparent process with the patients and families.

  • ¬†The status quo for the way we handle mistakes creates multiple victims, but no winners. ¬†[00:40]

    • When a mistake is made in a hospital, the common response is to pretend that it never happened. And then if it‚Äôs discovered, we‚Äôve learned to deny and to defend, before beginning a prolonged process of resolution.¬†

      • This adversarial process leads to a lost opportunity to learn from the mistake, on the individual and institutional level. It also prevents providing closure to the victim of the mistake.

      • Our approach to managing adverse events often comes under the guise of risk management.¬† But perhaps we need to reframe these events from managing risk to managing patients.

    • Who are the victims of our current¬† risk-management strategy?¬†

      • The patient:¬† According to the Institute of Medicine, the liability system is the number one impediment to patient safety.¬† Further, when something bad happens and compensation is deserved, the patient receives 30 cents on the dollar.¬† The rest goes to administrative waste and legal fees. Oftentimes, the patient never even receives an answer when a major adverse event happens.

      • The provider:¬† Providers spend much of their careers worrying about and trying to avoid lawsuits. And when lawsuits happen, there are significant impacts in terms of depression, substance abuse, and burnout.

      • The whole system:¬† One study showed that we spend about $1.4 billion a year on defensive medicine. That is a significant impact on health care costs.

  • It was the aftermath of an unfortunate case that sparked Smulowitz‚Äô interest in this subject. It motivated him to try to make systems better so that others did not have to go through the same trauma. [03:40]

Case

A 24 year old man presented with thoracic back pain after lifting boxes.  An MRI was ordered due to a history of substance abuse and was read as normal.  In the ED, the patient had a sudden PEA arrest and died. The MRI was re-read as showing an aortic abnormality.

    • Smulowitz felt horrible after this case. He had zero confidence in himself, and he almost quit practicing medicine.

    • The hospital‚Äôs response was not ideal.¬† Risk management advised that he only speak to a psychiatrist about the case.¬† He felt completely alone.

    • He imagines the patient‚Äôs family must have felt terribly as well.¬† They couldn‚Äôt talk to anybody about what had happened. Even though the case settled, Smulowitz isn‚Äôt sure they ever truly got answers.¬† And they probably have no idea how badly he felt.¬†

    • Smulowitz regrets that he didn‚Äôt have the chance to talk to the family and to apologize that such a horrible thing happened to their loved one.¬†

    • The current practice of pretending that bad things don‚Äôt happen is absurd.¬† We‚Äôre going to make mistakes, and we practice in imperfect systems where bad things are going to happen to people despite our best efforts.

    • The institutionalized isolation that we‚Äôre almost obliged to enter after an adverse event contributes to the second victim syndrome.¬† The patient is the first victim, and the healthcare provider, who is traumatized by the event, is the second.

  • We are taught not to apologize after an adverse event. But is this good advice? [11:00]

    • Many states have apology laws which protect you either partially or fully when you admit fault after an adverse event.¬† But Smulowitz believes these are almost useless in terms of their ability to protect from legal action. The laws are in place primarily to support and promote the apology process.

    • Excerpt from an¬†article¬†about apology laws:¬†¬†

‚ÄúAlthough physicians may feel the need to apologize after an adverse medical event, physicians‚Äô gut instincts to apologize are often hampered by the fear that their statements will be used against them in court.¬† This fear is further solidified when their attorneys advise them to be careful not to admit fault or liability. This seemingly well thought out strategy to remain silent actually creates an unexpected paradox. Refusing to apologize can precipitate litigation to an even greater extent.¬† Consequently, the lack of an apology can dilute the doctor-patient relationship, hinder patient safety, and increase litigation.‚Ä̬†

    • Communication is critical and an apology can be beneficial.

      • It is the responsibility of the provider and the hospital to communicate with patients in the aftermath of an adverse event.¬†

      • An apology is not an admission of fault. Apologies are beneficial to the physician as long as you‚Äôre not saying something crazy within the apology. Apologizing for something bad happening can be protective in the court of law because it makes physicians look like human beings.

  • Communication, Apology, and Resolution (CARe) programs have been developed to bring providers out of the shadows, encouraging them to talk about adverse events and encouraging a transparent process with the patients and families. [13:05]

    • Communication¬†-- There should be early and ongoing communication in the aftermath of an adverse event.

    • Apology¬†-- There should be an apology when mistakes happen.

      • Sample verbiage:¬†¬†‚ÄúIt is so horrible that this bad event happened to you. We are devastated that this occurred. We are going to continue taking care of you/your loved one and our hospital is going to be carefully reviewing what just happened.¬† We‚Äôre going to get back to you with the results we find.‚ÄĚ

    • Resolution¬†--¬†

      • Make sure that patients receive just and timely compensation when bad things occur that are directly attributable to deviation from the standard of care.¬†¬†

        • Note that some patients/families do not desire financial compensation and just want explanations.

        • Patients who receive financial compensation through CARe must sign a waiver saying they will not later file a lawsuit.

      • But if the adverse event is not attributable to negligence or the lack of standard of care, there should be robust defense of the hospital, provider, or system. Providers should be supported if the event was outside of anybody else‚Äôs control.

    • Institutionalizing this process is the only way to make it work, because you have to tie the communication and the apology piece to a true, just, and timely resolution.

  • How would you apply the CAR process to this hypothetical scenario:¬† a young woman with a viable pregnancy is mistakenly given methotrexate (which was ordered for the patient with an ectopic in the room next to her)?

    • First, the provider needs to communicate the mistake to the patient.¬†¬†‚ÄúYou were given methotrexate and we don‚Äôt know the reason for it yet.¬† We also don‚Äôt know what the outcome will be for you. We‚Äôre going to continue to investigate what happened and we will continue to support you.‚ÄĚ

    • Second, the error should be shared with your institution‚Äôs designated contact people responsible for investigating adverse events.¬† This could be the ED director, the chief medical officer, OB/Gyn, and/or the risk manager. Their involvement early on is necessary for communicating to the patient what the likely possible outcomes might be and how they‚Äôre going to continue to provide care and support.¬†

      • The rule of thumb is that the more severe the case, the more the institution needs to pull together quickly to discuss what‚Äôs going to be said, how it‚Äôs going to be said, and who is going to say it.

    • Third, there will be a point person who will follow along with the patient and be continually communicating. This should not be the initial treating provider.¬†¬†

    • All hospitals should have the infrastructure to provide ongoing support to patients when untoward events happen.

  • What is the best way to deliver bad news and apologize effectively? [21:20]

    • The core of an apology is an explanation which demystifies the offense, but does not excuse it.

    • Make sure that the facts (as you know them) are delivered. Don‚Äôt go above and beyond what you think you can explain. And don‚Äôt blame yourself or anybody else.¬† Be honest and transparent. Deliver it in a way that makes the patient feel supported.

    • At Smulowitz‚Äô institution they have put in place ‚ÄúJust-In-Time‚ÄĚ coaching.¬† When something bad happens, you can page someone who has years of training and can coach the provider on what to say, what not to say, and whether he/she is the right one to say it.

  • The University of Michigan made the CARe program an institutional process. What happened after they started using it?¬† [22:05]

    • They saw a dramatic reduction in the number of claims, the number of lawsuits, and overall costs related to lawsuits. Equally¬† important, there has been a dramatic increase in the number of incident reports.

    • Those results have been replicated at several other large institutions.¬†

  • What are the barriers and strategies for implementation of CARe programs? [25:55]

    • Providers are wary of it.¬† They feel vulnerable.

    • Hospitals are worried they will be paying a lot of money due to an increase in lawsuits.

    • Some plaintiff and defense attorneys are against these programs.

References:

Bell SK, Smulowitz PB, et al. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q. 2012 Dec;90(4):682-705. PMID: 23216427.

Davis, Erika R. I'm Sorry I'm Scared of Litigation: Evaluating the Effectiveness of Apology Laws. The Forum: A Tennessee Student Legal Journal. Vol. 3. No. 1. 2016. 

Mello MM, et al. Communication-and-resolution programs: the challenges and lessons

learned from six early adopters. Health Aff (Millwood). 2014 Jan;33(1):20-9. PMID: 24395931.

Shostek, Kathleen.  Communication and Resolution Programs:  Where are we now?  American Society for Health Care Risk Management. 2017 Jun 28.

McDonald, Timothy B., et al.  Implementing communication and resolution programs: Lessons learned from the first 200 hospitals. Journal of Patient Safety and Risk Management. 2018 April 11.

LeCraw, Florence R., et al.  Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee.  Journal of Patient Safety and Risk Management 23.1 (2018): 13-18.

Oct 03 2019

31mins

Play

We are an N of One - Essentials of EM Keynote (Video)

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This is the keynote address from Essentials of Emergency Medicine 2019. Transcript below...

There are moments in this job that are glorious ... magnificent.   The great save, a moment of kindness, and unexpected show of gratitude, nailing a difficult procedure or diagnosis. There are times that this job will make you want to cry tears of joy. Think about the last time you felt that way

There are moments in this job, however, that are dark. Moments when we, inside, feel Darkness. While I was putting this talk together, a friend of mine texted me that a patient had just died, it was a young man who had bee alive and laughing the day before.  Darkness. We see death, feel stress, see cruelty, feel burnout. At the end of some shifts, you feel so beat down it’s an effort just to think. There are times when this job will make you want to just... cry. Think about the last time you felt that way.

There are very few callings in life that evoke such extremes of emotion.  And these extremes happen in each one of us, individually. 

You do the work and have your own unique experience. You are the one that goes to the shift. You are the one who feels the excitement, feels the anxiety. It's all inside of you. An N of one.  

But Being an an N of one can be lonely, isolating. Yet here's the thing. In this room, look around....

In fact, and I know that this feels weird but, take 20 seconds. Turn to the person on either side of you and say hello and introduce yourself, tell them your name, where you’re from and them give them a high five. 

That person you just met, as well as everyone else you see in this arena… this is your tribe, your team. It’s a big team. No matter how big it is, though, we are a collective with shared experience, knowledge, and ethics. Whatever sad, joyous, crazy thing you see or do, these people, your people, are right there with you. 

You know...50 years ago, this group, this specialty barely even existed.

I can remember my dad, whose formative years were in the time when there was no one who specialized in emergency medicine. When I told him I wanted to be an Emergency Physician, he said ‚ÄúWhy are you going to waste your time doing that, is that even a real job?‚Ä̬†

That was how much of the world saw us.

Let’s be honest, we still get asked by some of our patients, "What field we’re going into when you’re finished rotating through the ER?"

In the big picture though,  we are now leaders in the house of medicine. You could say our specialty is a leader, but more so, it’s our community. How empowering to be part of something larger than ourselves where the ethos is to care for others in the best possible way. 

You may be a first year resident, new nurse, in paramedic academy, or maybe you’ve been doing this for decades, a grizzled old dog. It doesn’t matter. What we do in each day is the same. 

Think about walking into your shift. There is endless potential. And in that day, you will treat the young, the old, Rich, poor, drunk sober. Care for the the well, and the dying.

Taking on the difficult and dirty tasks, doing what most others don’t want to do. Doing it 24/7/365- weekends holidays, nights, days, and we get the job done with a smile and a common goal of excellence. We. Our community. 

And that community is made up of of each of you, each of you with your own story. Each of you an N of one. Doing hard work, good work. Each of you is like a single drop whose ripples change the world. 

You are emergency medicine. 

Aug 27 2019

9mins

Play

Decision-Making Capacity, Newsletter, and The Pale Blue Dot

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In this episode we discuss the elements of documenting a patient's decision-making capacity, pearls from the last month of ERcast, our new newsletter, and Carl Sagan's Pale Blue Dot.

Links from this episode

  • Sign up for the ERcast newsletter HERE
  • THIS is the newsletter discussed in today's podcast
  • If you want to learn more about the full on, full cowbell, full BAFERD, total ERcast experience, Click Here

In case the links above don't work

Aug 25 2019

21mins

Play

Acute MI in Cardiogenic Shock with Weingart and Mattu

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Scott Weingart and Amal Mattu are our guests as we break down the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.

Want weekly episodes, world class show notes, CME, and a super sweet app? Go to ercast.org and subscribe to the kit and caboodle.

Jul 06 2019

39mins

Play

Infected and Obstructing Nephrolithiasis

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Patients with infected ureteral stones present a true medical emergency. I very well may be obvious what's going on but, often, it's not so clear. Maybe the patient has no fever but a few white cells in the urine, or maybe they look sick but have a negative UA. In this wide-ranging discussion, we interview urologist Nora Takla about her approach to infected stones, how she manages those with equivocal presentations, as well as the logistics following up non-infected stones, the significance of extravasation on CT scan, and the sometimes surprisingly complicated decision making when it comes to admitting ureteral colic patients.

Subscribe and hear the rest of the show.  CLICK HERE! For access to more incredible education and 2.25 hours of CME each month. 

Apr 13 2019

33mins

Play

How to Use the Pulse Ox Like a Boss

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From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.

Pearls:

  • The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.

  • For patients ¬†breathing room air, pulse oximetry can be used to monitor for hypoventilation. ¬†
  • Nail polish has minimal impact on the accuracy of pulse oximetry.
  • If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.

  • ‚ÄúThe respiratory rate is the most vital of the vital signs.‚ÄĚ ¬†¬†¬†Experienced doctors look at a patient who seems well, but understands that they‚Äôre not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately. ¬†Since we don‚Äôt always have access to reliable respiratory rate, Strayer‚Äôs go-to vital sign is the oxygen saturation.
  • ‚ÄúReusable pulse oximeter probes are gross.‚ÄĚ ¬†One study found that even when these probes are cleaned by standard procedure, ‚ÖĒ had bacteria cultured from them. Strayer recommends using single use probes in your department.
  • Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923.
  • Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal. ¬†
  • Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect. ¬†
  • If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger.
  • Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149.
  • As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.

  • Significantly hypercapnic patients saturate less than 95% when they‚Äôre breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing.
  • If you need to give supplemental oxygen, then use capnography to monitor respirations.

  • The pulse oximeter does so much more than provide oxygen saturation. ¬†

  • It provides the photoplethysmogram (PPG) which is a waveform that tells you the ‚Äúmechanical‚ÄĚ heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.

  • The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high). ¬†The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF.
  • Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670.
  • van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972.
  • What if you don‚Äôt have a reliable pulse ox tracing?

  • Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there‚Äôs a lot of ambient light.
  • If you‚Äôve corrected for these problems and you still don‚Äôt have a good tracing, you should be concerned that the patient is poorly perfused.
  • One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status. ¬†
    • Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.

  • How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?

  • One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin. ¬†
  • The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning.
  • The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead.
  • Functionally, ¬†it doesn‚Äôt seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger. ¬†For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.

  • Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891
  • Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826

  • DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link.
  • Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227

Mar 11 2019

20mins

Play

Essentials of EM: Post Tonsillectomy Bleed

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Not all post tonsillectomy bleeds are created equal, and not all portend decompensation into hemorrhagic shock (though some do). Emergency physician Gene Hern and ENT surgeon Clay Finley give their thoughts on approach and management.  

Feb 11 2019

26mins

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Thrombolytics for Frostbite

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Managing frostbite is both simple and complex. It's been around since human skin met the cold but  research within the past few decades and even the past few years has dramatically changed how we care for  thermal cold injury. in this episode, frostbite expert and burn surgeon Dr. Anne Wagner discusses frostbite diagnosis, simple and advanced management.

Jan 07 2019

12mins

Play

The Chest Pain Summit

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A consensus summit with world experts and primary researchers focused on the question, ‚ÄúAfter a negative ED evaluation for ACS, is an expedited outpatient evaluation a safe alternative to admission?‚ÄĚ Featuring¬†Colin Kaide, MD, Mike Palacci, MD, Barbara Backus, MD, Erik Hess, MD, Ezra Amsterdam, MD, Douglas Van Fossen, MD, Rob Orman, MD, Mike Weinstock, MD, and Cam Berg, MD

Dec 02 2018

28mins

Play

Evidence Based Hyperkalemia Management

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Hyperkalemia is one of, if not the most, common electrolyte abnormalities we see. But much of what we do in treatment is what someone told us to do when we were young learners. In this episode we debunk hyperkalemia myths and discuss an evidence based approach to management. For more great content check out 

https://www.hippoed.com/em/ercast/

Nov 07 2018

34mins

Play

When to call a code in the field-Essentials of EM

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Corey Slovis, MD from Essentials of EM 2016 breaking down when to call a prehospital code, and when to keep the resus going.Check it out https://www.essentialsofem.com/

Nov 01 2018

9mins

Play

Las Vegas Mass Casualty: How one ED made order out of chaos

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A first hand account of the emergency department response to the 2017 Las Vegas strip shooting that left 59 dead and over 800 wounded. Discussion of preparation with 20 minutes warning, how to keep patients flowing as they enter the hospital as well as once they’re in the treatment area, effective triage, critical steps to simultaneously resuscitating large numbers of trauma patients.

Oct 08 2018

33mins

Play

Emergency Complications of Cirrhosis

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Britt Long, MD and Rob Orman, MD discuss emergency department management of patients with complications of cirrhosis.

Sep 04 2018

30mins

Play

The Dying Asthmatic

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  • Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy.¬†¬†Asthma is different than other causes of severe respiratory distress. ¬†And there are different forms of asthma as well.

  • Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case?

    • Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management.

    • In the rare cases of severe asthma with a ‚Äėstone chest‚Äô that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible. ¬†It‚Äôs the only way to safely provide the airway pressures you need.

      • Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration.

      • Failed attempts at intubation are especially risky in these patients. ¬†As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.

Aug 06 2018

31mins

Play

Why Epi Might (and might not) Work in Cardiac Arrest

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The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.  

20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed.  Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission.

Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate.  Also, amongst the survivors, the neurologic outcome was worse.

Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful.

The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period.  These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.

Jul 01 2018

22mins

Play

Internal Medicine in the Emergency Department

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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

25mins

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Massive GI Bleed on Anticoagulants

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

May 04 2018

30mins

Play

Mind of an Addict

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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

22mins

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