October 2017 - Hotpocket
Lessons Hard Learned In The First Year As An Attending
BackPassage October 2017
Mel gives an update and insight on what's happening at EM:RAP.
EMA, Swadron, Herbert & Bundt Cake Goodness!
This is a historic month, the month Emergency Medical Abstracts joined EM:RAP! The historic series with 30 plus papers and all new commentaries is now part of EM:RAP, are you kidding me! It also means a new app and web site! Say what! It is the return o da Captain and his Little Ozzie Friend, if only for the month. Also includes: Notes from Uganda, dental infections, what works in cardiac arrest, what to do with “mini-strokes”, should you have MRSA in that cellulitis patient, a bunch of male GU issues, 30 EMA papers, 5 Paper Chase, I mean come on EMRAP just exploded!
C3 - Atrial Fibrillation
Atrial fibrillation (AF) is the most common tachyarrhythmia. As such, AF is bread and butter for the emergency provider. We need to really understand and be comfortable with this rhythm.
EMA October 2017
This month’s EMA episode includes Reflections of a Skeptic: The History of EMA, That Was Then This is Now: Magnesium in ACS, Time To Talk A Little Nerdy: TIAs, Rick's Rants: Fluoroquinolone Black Box Warning, Jerry’s Deep Dive, The Ultra Summary, and 30 abstracts.
September 2017 - Hotpocket
You’ve probably seen the news story: an ED nurse is handcuffed by a Utah detective for refusing to draw blood on an unconscious accident victim. Nobody wants something like this to happen, but are we compelled to act as agents of the police for evidence collection? Legal experts Scott DeShields and Rich Orman weigh in.
EMA September 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “CT Coronary Angiography, Pros And Cons”, an essay “The Ring Of Fire”, an interview “Listener's Memories Of Em Abstracts”, and reflections of a skeptic “Listener's Choice”.
Your next patient is altered and blue. Blue as a blueberry. What on earth could be happening? We travel to the backwoods of the American south to find out. Isn’t it time the Framingham risk factors got a remodel? Amal says yes, but the bigger question might be, “Do we care?” A painful tooth that doesn’t look infected, is there an indication for antibiotics? Vanessa Cardy wonders about the road not taken when managing a critical pregnant patient in the hinterlands. Walker Foland thumps the precordium with surprising results. And the original Swami digs into the infinite sea of trauma myths.
C3 - Seizures in Pediatric Patients
How should we approach seizures in pediatric patients? How different is this from adults with seizures? We will discuss.
August - Against Medical Advice Correction
In our AMA segment this month, it was stated that a patient who leaves the ED against medical advice is at risk for their insurance company not paying the bill. We have been inundated with emails saying, “Is that really true? I heard it was a myth…” It turns out that this IS a myth! Thank you for helping us set the record straight. Listen in for details.
Suicide Risk in Physicians
Mel Herbert MD, Christine Moutier MD, Ramin Tabatabai MD, and Matthieu DeClerck MD touch on suicide risk in physicians. How did we get here and now what do we do about it?
EMA August 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Ketamine Analgesia In The ED”, an essay “The Opioid Epidemic; Is Emergency Medicine To Blame? What Is The Number Needed To Suffer? Is Dr. Stingy Better Than Dr. Feelgood???”, an interview “Do Heroin Overdose Patients Require Observation After Receiving Naloxone?”, and reflections of a skeptic “It's The Malpractice System That Is Negligent”.
C3 - Seizures
Seizures frighten everybody. They can be distressing not only for patients but also for their families, public bystanders and even emergency providers. Because the convulsions associated with seizures can be so dramatic, we tend to lose our ability to think in a logical manner when a patient is actively seizing. In this episode of C3, we cover the initial approach to the seizing patient, how to manage status epilepticus and how to disposition these patients from the emergency department.
Challenging Foleys, Conversations, and Intubations
Rob and Swami kick things off with a case of a patient with a red hot arm who ends up with a surprising diagnosis. Having trouble placing that Foley cath? Not to worry, Jess does a cognitive biopsy of our urology consultant for a bevy of tips and tricks. Vitamin C might not cure the common cold, but can it save septic patients? How often to we intubate for true ‘airway protection’? Strayerisms says not as much as we think. EM stroke expert John Schrock makes sense of BP control in acute stroke patients. Kevin Rodgers and Mike Weinstock are AMA. This, and so much more I'm the August extravaganza...
July 2017 Hotpocket
First some information on the FIX conference with the FEMinEM people. Mel presents ANOTHER case of a sick patient in a plane and lesson learned, and a challenge coin winner Dr. John C. Maino, MD
C3 - Bradycardia
In last month’s C3, we discussed the concept of primacy of rate. Simply stated, the more abnormal the heart rate, the more likely that it is responsible for the patient’s symptoms. In most cases (but not all - e.g. not in hypothermia and myxedema coma) intervening to correct the rate is a high priority in the resuscitation.
EMA July 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Traps When Assessing The Medical Literature”, an essay “Low Back Pain”, an interview “Digital Pills To Measure Opioid Ingestion Patterns In Emergency Department Patients With Acute Fracture Pain: A Pilot Study”, and reflections of a skeptic “Overuse - What Can We Do About It?”.
Sugar Up, PE Home, O2 Cranked
When it comes to preoxygenation, consider the Nigel Tufnel approach of turning the amp up to 11. How much do we really know about OTC analgesics? Delaney is back with some surprising news. Weingart solves the puzzle- how much lack does lactate lack if lactate lacks lactate? There are all sorts of meds we give to ACS patients, but do they do any good? Last month George Willis tackled low sugar, this month, he shoots for the moon. The new drug of abuse may shock you...gabapentin! And just where are we on abx for acute appendicitis? Somewhere in the middle.
June 2017 - Hotpocket
It seems like the more we know, the less we do. Rob and Mel review two articles in the ‘less is more’ category
EMA June 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Errors In Trauma Management 2016 - Part 2”, an essay “Caring For Emergencies In An Aging Society”, an interview “The 2016 Academic Emergency Medicine Consensus Conference, Shared Decision Making In The Emergency Department: Development Of A Policy-relevant Patient-centered Research Agenda”, and reflections of a skeptic “When Doctor Becomes Patient”.
Don’t Fear The Stink!
We are masters of working in malodorous conditions. But just because we can tolerate the toxic sock, doesn’t mean we have to. Strayer soothes the hulk. Is the Hare Traction Splint useful? Amal breaks down the ‘warranty’ on different cardiac studies. Stuart and Billy get super funky with an obs case gone bad. How long do we need to obs a pt who has rebounded from hypoglycemia? Endocrine expert George WIllis breaks it down. Scott W tries to shrink the brain and Vanessa Cardy manages a critical vag bleeder in the hinterlands.
C3 - Tachyarrhythmias
Managing patients with tachycardia is as central to emergency medicine as airway, breathing, and circulation. In many cases, a rapid heart rate is the most prominent and obvious part of a patient’s presentation – and in some cases it demands immediate action from the treatment team. In this episode of C3, we have attempted to make the approach to patients with tachyarrhythmias simple “but not too simple”, as a great man (Albert Einstein!) once said.
May 2017 - Hotpocket
Our recent segments on stoke updates and naloxone dosing have set off a storm of controversy!
Red, Hot, and Shot
Do you discuss anxiety with your low risk chest pain patients? Jeff Kline says it might not be a bad idea. Kenji and Miz demystify the penetrated extremely. Stroke care continues to evolve, Ryan Radecki tells us how. Is that red, swollen leg really infected, or is a case of pseudocellulitis. Tim Horeczko dissects the tests for septic joints in kids. What is ROSC? It seems an obvious question on the surface, but clinically it's not always clear. Scott Weingart takes it on with alacrity and a rapier wit. This and so much more on this month’s EM:RAP...
C3 - Epistaxis
Epistaxis, or nosebleed, is among the commonest presentations to the emergency department. Although epistaxis occurs in the majority of people at some point during their lives, most are minor and self-limited. Those patients who arrive to the ED represent a specific subset of nosebleeds - ones that won’t stop. These patients may be quite anxious and fearful. In some cases there are underlying reasons why the bleeding won’t stop. Fortunately, we have a wealth of tools, tips, and procedures to stop the bleeding.
EMA May 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Errors In Trauma Management 2016 - Part 1”, an essay “Unscheduled Pacs And Ehr Downtime: The Most Common Multi-casualty Incidents (Mcis) In Emergency Medicine Today”, an interview “Practice Characteristics Of Emergency Department Extracorporeal Cardiopulmonary Resuscitation (Ecpr) Programs In The United States: The Current Sate Of The Art Of Emergency Department Extracorporeal Membrane Oxygenation (ED Ecmo)”, and reflections of a skeptic “Standard Of Care”.
The Dark Side of EM
Mel Herbert speaks to Ramin Tabatabai about resident wellness and one recently discovered deeply disquieting fact regard physician wellness, or lack of it.
Some New P’s for RSI
In this month’s short, Darren Braude connects with Calvin Brown, MD. Calvin is the editor of the upcoming 5th edition of The Manual of Emergency Airway Management. There are lots of new goodies in the book, but the two we focus on are: Pretreatment (it’s out) and Preoxygenation (it’s better).
EMA April 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Sah Ongoing Diagnostic Challenges”, an essay “Maintenance Of Certification: Is The Juice Worth Squeeze?”, an interview “Comparison Of Intravenous Ketorolac At Three Single-dose Regimens For Treating Acute Pain In The Emergency Department: A Randomized Controlled Trial”, and reflections of a skeptic “Screening - Do The Math”.
C3 - Dizziness
Dizziness is a poorly defined symptom that plagues both patients and clinicians. It is one of the most common chief complaints in both emergency and outpatient settings, accounting for millions of visits to each annually in the U.S. alone. There is often uncertainty surrounding the clinical approach to the dizzy patient and the wide variation in practices is what makes it particularly difficult for new and seasoned practitioners alike.
Little Tubes, Little Labs
What’s the most powerful computer ever? The one between your ears. Using that to visualize and simulate ED challenges can have profound results. Tim Horeczko gives the skinny on which adult labs also work (or don’t) for kids. Is your patient in a coma? Wendy Chang helps us examine unconscious patients. Bill Reed throws down a call to action for us to use blunt tip needles for LP. And a GSW to the chest in the Great White North.. what do you do when your patient is dying and the closest trauma center is 10 hours away?
VX Nerve Agent
VX has been in the news recently as the suspected agent used to assassinate Kim Jong-nam (half brother of North Korean leader Kim Jong-un). What is this stuff? What’s it do? Stuart Swadron and Sean Nordt cover mechanism of action, presentation, and management of patients exposed to this weaponized organophosphate.
Are NSAIDS Lethal?
Headline from The Guardian March 15, 2017: “Calls for ibuprofen sale restrictions after study finds cardiac arrest risk.” Is there now nothing that can be used for analgesia?!?
Rob and Swami kick things off with something for which most of us never received formal training: calling an admission. Does your patient need something for pain? Reuben Strayer says be smart about it and use an algorithmic approach to decide whether or not to use opioids. A patient slowly crashes in a rural ED - Scott Weingart breaks down the play by play. How do you figure out a patient's weight for setting tidal volume? Al Sacchetti says, “Use a tape measure.” And did you ever wonder how you should clean and prep a laceration? Probably not, since you’ve done it so many times, but things you learned in the ‘old school’ might be ready for a new approach.
EMA March 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Evolving Legal Issues In Emergency Medicine”, an essay “Can We Safely Remove The Lumbar Puncture From The Subarachnoid Hemorrhage Work-up?”, an interview “Identifying Vulnerable Older Adults In The ED”, and reflections of a skeptic “Listener's Choice”.
C3 - Chest Pain
Chest pain is the second most common chief complaint in the ED, with over 8 million visits annually in the U.S. alone. Chest pain evaluation is challenging but very manageable with the current systems and protocols in place in many hospitals
Burn Out - Calling a Consultant
The first in a series on burn out in Emergency Medicine. In this episode, Mel Herbert talks about the anxiety of calling consultants and how he dealt with it. Jess Mason calls for a different approach.
Influenza Treatment Pathway
Do you ever feel confused as to whom should be tested and/or treated for influenza? Rest assured, you’re not the only one. Cam Berg simplifies the process with a seasonally topical ‘influenza clinical pathway’.
EMA February 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Sleep And The Em Professional”, an essay “Best Of 2016: Commentators Pick Their Favorites”, an interview “Transvenous Pacemakers In The ED”, and reflections of a skeptic “Patient Satisfaction Vs. Patient Expectation”.
Bad Bleeds in the Brain and Pelvis
How good are you at accepting a compliment from a patient? Do you take the time to listen, or do you end up giving more attention to complaints and insults. The Happy MD gives tips on how to make expressions of gratitude meaningful for you and your patient. Cam Berg is back with an ADP for the evaluation of subarachnoid. What are the critical tests in a patient with threatened miscarriage? Dave Glaser says there is but one. Jedi Master Chris Hicks imparts wisdom in the ED management of pelvic fractures.
C3 - Pediatric Abdominal Pain
As with the elderly, children with abdominal pain are special and require a different diagnostic approach. In this episode of C3, we will consider the general approach to abdominal pain in children.
High Sensitivity Troponin FDA Approved
It’s been years in the making and, at long last, a high sensitivity troponin assay has been approved for use in the United States. Is it such a good thing?
Mel intros the concept of a new behind the scenes show for the EM:RAP audience...with Rob O and Jess Mason...
January - Hotsheet - The Great C-Collar Debate
In our February 2016 episode, we had a segment titled Do we still need the C-Collar. This caused quite a bit of debate amongst the listenership as well trauma specialists across the globe. We can’t give a definitive answer as to the utility of cervical collars, but what we can give is a ringside seat to both sides of the argument. Andy Buck and Chris Colwell are here for round two pros, cons, and ‘we don’t knows’ of the great c-collar debate.
EMA January 2017
This month’s EMA episode includes 30 abstracts, a bonus lecture “Management Of The Injured Finger”, an essay “The Fragility Index: Assessing Usefulness Of Randomized Clinical Trials”, an interview “Balance Billing And The Nejm: The Emperor Has No Peer Review?”, and reflections of a skeptic “Opiates - Too Much Or Too Little”.
Broken Ankles, Ribs, and Pumps
Happy New Year! Swami kicks off the festivities with a case of fever and tachycardia that’s … not sepsis. Is point of care urinalysis a good idea in kids. Sam Ashoo breaks down the evidence. Orthopod Uma Ramadorai gives a primer on diagnosis and treatment of ankle fractures. How nervous should you be about rib fractures in the elderly? Kenji says, “Be pragmatic.” Weingart rounds off the head trauma trilogy with a masterclass on micro and macro-management. Strayerisms is all about preventing ETOH withdrawal before it even starts. And even though dying palliative care patients may not get critical care procedures, they still warrant active management.
C3 - Elderly Abdominal Pain
Elderly patients with abdominal pain represent a special population that is much more likely to have a serious life-threatening cause than almost any other presenting complaint.