Introduction

Richard S., Dr -

Content is always great but Audio this month is "The Dogs B*ll*cks" nice one!!!

Rob O -

Hi Richard. I'm hoping that that is a good thing!

Richard S., Dr -

It is a very good thing indeed! I have been glued to these podcasts since discovering them, keep up the good work...

Anna H. -

I'm trying to find the antibiotic flowchart you guys mentioned would be in the notes. Where can I find it?

Anand S., M.D. -

Anna - We'll need to update the notes with the flow diagram. Coming soon

Rob O -

Hi Anna,
Here is the article in question.

http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/FN.pdf

The table is on page 68

Daniel O. -

also good bedside guide on wikem.org http://www.wikem.org/wiki/Neutropenic_fever

Adrian L., M.D. -

Just a few thoughts.

Trauma transfers- I think a native hip that was dislocated would be the one other ortho trauma I would consider reducing prior to transfer because of the time sensitive nature.

And by the way, 2 is a prime number. (In the rule of 2's section when someone goes for "a prime number", it was just too funny. Thanks)

Jessica R., M.D. -

Some thoughts on this month's edition:
-If the authors in Paper Chase 1 wanted a truly accurate mnemonic, it would be called the ARSE trial. Which I think Mel would love.
-I was never trained to insert a Heimlich valve instead of a thoracostomy tube. I don't even think we have pigtail catheters in the ED in our shop.
-Very glad to hear we don't need the invasive CVP monitoring in sepsis. We get our fair share of it in our rural hospital and we almost never put a CVP line in. I don't even think we can display that on our monitors.
-"Assistant physicians"-- terrible idea. Just thinking about how terrified I was as an intern and how very, very much I still had to learn (those ICU nurses saved my behind more than once!) I can't imagine being unsupervised at that level. That's an 007 if ever there was one.
-Just because it may not decrease the amount of testing does NOT mean we do not need malpractice reform! Raising the standard as described in the article needs to be at a federal level. I wish they would do that in my state but probably never gonna happen.
-Overall, I learned a lot and will try to improve my practice with these suggestions. Thanks for your interest in my long-winded opinion.

Christopher S. -

I just finished a residency in South Carolina and I have to say I didn't notice (or even know about) malpractice reform in the state. We still ordered plenty of CYA testing and even called it that as we were discussing the plan with the attending. Even if the process is reformed, I think there is still the fear that you will be the one physician who does get targeted. Even if nothing comes of the legal action, there is no physician who wants to go through the time, effort and money involved in a lawsuit.

paul f. -

Concern over lawsuits has always driven some over testing, but I have also noted that large Contract EM groups tend to push extra testing through encouraging laoose Nursing order sets and mandatory Risk Management modules that imply that almost every chest pain would need an admission and any abdominal pain would need a CT. By pushing more complex workups and moving patients quickly to disposition, the MD has less time to ponder over a case, to allow for any observation time in the ED, and merely begins to just "follow the protocol". This obviously benefits the Group and the MD financially. Another concern is that our practice is scrutinized by all forms of bureaucrats, both in the hospital, the "State" and the "Fed", and protocols not followed are often questioned by these entities and we often do excess testing to prevent this.
Of course Tort reform would eventually help and i think the above comment by Christopher shows that many of the MDs were not aware of the reform

Mathieu M. -

Catching up on my EM:RAP episodes.
Did I heard it correctly: are you suggesting to do rectal temp on your neutropenic patients?
Continue the good work!

Rob O -

Mathieu,
Thank you for your comment. Rectal thermometry is certainly NOT recommended in the neutropenic patient, as you intimate by the closing of your post. I was aghast that we had even suggested such a thing on the show. Listening to the audio, Swami says, "oral temp offer 101 or sustained temp over 100.4 for an hour...does the person have to have a continuous rectal thermometer in...?"

I think this reference alluded to a lack of direction from the professional societies regarding the exact method of measuring continuous temperature in the neutropenic patient, rather than an endorsement of rectal thermometry. I appreciate you noticing the potential for confusion/inference to an ill advised practice.

Barbara W. -

Just had to share, last shift I had a young (18) woman come in in clear respiratory distress. The triage nurse brought her in the moment she saw her. Moving very little air with a little chirp with every attempted inspiration. Unable to talk at all. Pharynx looked normal. Sats OK, but still scary. No history of asthma, no allergy history or trigger. Ahah I think this is vocal cord dysfunction! I listen to EMrap, so I'm smart! A little ativan and CPAP later (plus a little epi just in case) and she settled well. Went home 2 hours later happy. Thanks so much EMrap.

James F., M.D. -

I had an ED registration clerk who has had many periodic spells of acute dyspnea, anxiety, tacycardia and hypoxia, and has been intubated by several of my partners (and I) more than several times. No one has ever been able to figure out what was going on. After some observation in the unit, she was always extubated and seemed to be fine. No other allergic symptoms. Scopes were all negative. We tried benzos, methylprednisolone, mag, etc, all with no significant relief. The last time I saw her I gave her a single subdissociative dose of ketamine at 0.25mg/Kg IV instead of the typical whole 9 yards on a hunch that it might help. It broke her "spell" almost immediately. I wasn't sure on the pathophysiology but was excited to hear the discussion about vocal cord dysfunction. I'm going to have to hunt her down and pass along the drinking straw tip. This segment will have significantly changed her life...as well as cut down on her co-pays. Thanks! Great work!!!

James F., M.D. -

Another great tip for tissue adhesives are those annoying spontaneous varicosity bleeds and post-dialysis bleeds. Instead of spray painting graffiti on the walls in blood, I simply pinch the skin over the bleed site to give brief hemostasis, then plop a dab of Dermabond on the site. Voila! Done. The length of adhesion seems to be long enough for the most stubborn varicose blow-out to heal decently enough. I've not heard of any bounce backs with my technique. Dermabond...it's like duct tape, only cooler! If only the Professor had a few tubes in his pocket on Gilligan's Island they could have glued their boat back together and cancelled the show after the first or second episode!

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It is Hard to Breathe When Your Vocal Cords Don’t Work! Full episode audio for MD edition 251:25 min - 293 MB - M4AEM:RAP 2015 Février Résumé en Francais Français 60:40 min - 50 MB - MP3EM:RAP 2015 February Canadian Edition Canadian 14:10 min - 12 MB - MP3EM:RAP 2015 Febrero Resumen Español Español 95:30 min - 76 MB - MP3EM:RAP 2015 February Aussie Edition Australian 88:33 min - 81 MB - MP3EM:RAP 2015 February MP3 279 MB - ZIPEM:RAP 2015 February Summary 2 MB - PDFEM:RAP 2015 Español Febrero Summary 939 KB - PDFEM:RAP 2015 February:Board Review Answers 375 KB - PDFEM:RAP 2015 February:Board Review Questions 374 KB - PDF