Introduction – A Hot Red Arm

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Quinn -

EMRAP twins: JAFERD and BAFERD. You're welcome

daniel m. -

Anand referred to clindamycin "binding" toxin as the reason for giving this med in nec fasc.

I was under the understanding that this is a good idea because of The Eagle Effect, which refers to clindamycin's anti-ribosomal mechanism of action. When you add clinda the bacteria stop synthesizing toxin (recall that protein synthesis occurs in the ribosome), so the toxin-mediated effects are reduced.

Is there some new evidence that I'm not aware of, or did Anand misspeak?

Anand S., M.D. -

Daniel - I was always taught it bound the toxin but, I can't actually find anything of substance in the literature. I've just dropped your comments over to Greg Moran and we'll try to clear this up. Thanks!

Anand S., M.D. -

Daniel - we've got your answer from Greg and you are absolutely correct:

In terms of clinda: "It does not bind up the toxin, but the mode of action is ribosomal inhibition, so it reduces protein synthesis, and therefore toxin production. The "Eagle Effect" they talk about is not specifically that clinda works at the ribosome, but that in nec fasc streptococci are not actively dividing, but once they get to a certain number of bacteria in the tissue they tend to just sit there pumping out toxin but not reproducing. Therefore, antibiotics like beta lactams that work at the cell wall are less active. "

Yodda -

From the initial presentation I am not getting a sense of " was the pain and discomfort out of proportion to what you could see?".... this is my first clinical test . It's not CT, not CK, not WBC . If Things are the patient...several hours if need be. What do you think??

Andrew O. -

Just a heads up on Linezolid use...

so...A few months ago on EMRAP it was mentioned that Linezolid had gone generic over the last year or so. Much to my dismay, I wrote a script for Linezolid for a pt who bounced back the next day and told me that the price was roughly $2000. So I called the pharmacy and found that the brand Zyvox is roughly $4000 and now the generic knocks off about a grand or two. I was told by the pharmacist that it would be another couple years until the price became truly affordable.

Donald Z., M.D. -

Regarding ultrasound presence of cardiac activity without pulse how much cardiac activity are we talking about. I often see very minimal contractions that seem ( a assume ) agonal . Can you guide me to how much contraction i need to see to assume shock vs arrest?

Joshua M. -

EMRAP Twins:

NINDS 1 and NINDS 2. They both came out about the same time, they don't agree with each other's conclusions and they're the source of a lot of controversy. And, turns out, NINDS 2 is a serial killer. (I'll leave it to you guys to write that one into the script.)

ekiureghian -


Really enjoyed the segment on the AMA situation. I am, however, disappointed to hear you hint that insurance companies may deny payment if a patient decides to leave AMA. To the best of my knowledge and review of the literature this is a complete myth that we must stop spreading.
Ann Emerg Med. 2010 Apr;55(4):393. doi: 10.1016/j.annemergmed.2009.11.024
This actually factors into my AMA scripted discussion with patients. After going through my version of the process you outlined, I tell patients that this process and that the patients' informed decision in no way means that this has resulted in a contentious situation between the patient and me (from my perspective), that this in no way means that the patient should not feel welcome to return at any time should they change their mind or get worse, and that this in no way means that their insurance company will deny payment for services already rendered. Using insurance denials as veiled (or not so veiled) threats against our patients to coerce them into making the decisions that we feel are best for them needs to stop. If there is data or situations that I am not aware of, I would really like to hear about them. Otherwise, keep up the great work!

Emeen Kiureghian

Robert M. -


Thanks for adding your comment about insurance denials. I was also surprised to hear this statement made at least twice during the podcast.

Rob & Anand,

If you have information which shows that insurance companies really do deny these claims, I'd like to see it. My understanding is that there is at least one study showing that this is a myth.

Christopher P. -

Just a comment on the EM:RAP necrotizing fasciitis case from August, 2017. If you all have never touched on it, POCUS can be easily used to evaluate a septic looking patient with suspected necrotizing fasciitis (if you are still not sold on the DX) to rule it in. In many places, surgeons on call are happy to take a look at these images to strengthen the case for surgery. Especially if source control is needed, and there’s no time for CT. Happy to send along an example video, or add any other comments.


Chris Peluso, DO, FAWM
EM, University Hospitals- Cleveland Medical Center
Cleveland, Ohio

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