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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

No me gusta!

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Ryan A. -

I'm new to EM:RAP, so forgive me if there is an obvious answer to this question: Why does the pdf not follow the order of the episode chapters?

Mel H. -

Currently that is how it works. We are going to fix it soon!

Tracey M., Ms -

Hi guys,
Firstly, great site. Keep it up.
I am not sure if it is just me (maybe my Mac has had a melt down) but the December pdf summary is in Spanish. Can I get an english version.

Kevin G. -

Thanks for the goodness, again.
Osteomyelitis in diabetic ulcers can be found as discussed with probe-to-bone, and plain film - it can also be found sooner with CT, or best, MRI if access to that.
If non healing diabetic ulcer, a number of boxes need ticking - besides the obvious (and not ED job) addressing of diabetic control and of smoking, looking for fixable large pipe disease with arterial Doppler, ruling out FB, diet (low on zinc) and because sometimes it happens, consider is this an indolent malignancy not a diabetic ulcer.
A hyperbaric unit with a physician can address all these things: if a patient has insurance why not refer to them. HB will not cure osteomyelitis, but it might some diabetic ulcers with or without OM, in selected patients. Once the osteomyelitis is cured ( PICC ABs for 6/52 and luck, but even if amputation required, pre op hyperbaric oxygen may give a better result and less chance of further trip to OR) , the underlying small artery disease is still there. Hyperbaric oxygen therapy can, in some cases, heal these ulcers.
ED does have more of a useful role than this article seems to say, I think

Kevin G. -

Dr Weingart of Emcrit says put the critical care in the ED. Well, a diabetic foot ulcer is a slow burning emergency and requires slow but critical care.

David P. -

The diabetic foot is indeed a difficult problem. the section was informative, but I wish there were a few more recommendations for immediate intervention. The reality is, at least where I work, people with insurance and a pcp don't tend to come to the ed with giant diabetic foot ulcers. Those things can start fast, but generally take a bit of time to develop. Most reasonably observant people with resources don t let them get that far. Which leaves the unobservant and under resourced (homeless, mentally ill, non-english speaking, working poor, elderly with support trouble, substance abusers, people with cognitive problems etc). Those are the folks I see most often with this problem. They can be admitted, and often are, but quite a few don't need that. Giving them referrals to wound clinic (chronically overbooked), infectious disease, a pcp etc. do nothing to address the problem in the ED, and follow up is problematic. Some suggestions on debridement, building up a supportive shoe, etc were hinted at but not elaborated on. Perhaps in a follow up segment we could get some tips on how to improve the situation in the short term. Of course, to heal the damn things all that follow up needs to happen, but I'm just looking for some real world help on this.

Matthew D. -

Followup is tough in almost all settings and I think you're right on that we should do as much as possible when the patient is in front of us. For patients with significant edema writing for compression stockings can make a huge difference. In a patient with neuropathy an rx for diabetic shoes can be really helpful although the logistics of them getting these shoes and the associated paperwork can be tough in a busy ED. We can followup with Dr. Khoury and see about some more practical interventions that we can use at the bedside with these patients.

Debra S. -

Finding the Joy in EM...great podcast and advice, but what about us elders...the soon-to-be and newly retired. How do we go about dismantling careers spanning decades? The real question is how do you go from 5000 rpms daily to standing still in the blink of a defibrillation joule. I'd like to hear from those who have made the last walk past the triage desk and out the pearly ambulance portal.

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