Bits and Pieces
Our bi-montly session where YOU take the helm with… bloody pee, baby coughs, salty blood, Sam Ashoo's beef with blood pressure, and the power of silence. "
BRUE Works
A few years ago, ALTEs (Apparent Life Threatening Events) got reworked, renamed, and rebranded as BRUE. But did changing the name actually impact patient care? Clay Smith from Journal Feed is back to break down some recent literature answering just that question.
N of 1 -- The World’s Most Efficient ED?
Once a patient is placed in an ED room and bed, it can feel like time slows down. Unless they're dying, most systems don't have a rush order on getting things done. Florida emergency physician Michael White says things don't have to be that way. He has re-worked his ED's flow so that discharge length of stay is less than 80 minutes, patients are happier, and docs more satisfied.
EEM 2019: Non-pregnant Vaginal Bleeding
From Essentials of Emergency Medicine 2019, Ob/Gyn Megan Jones gives her simple approach to evaluating and treating ED patients with abnormal uterine bleeding.
Cardiac Transplant Patients in the ED
We should never trust the transplanted heart. Loss of innervation, no chest pain with MI's, infection, rejection, and vasculitis are just a few of the problems we can run up against. In this episode, ED intensivist Sam Wood gives us the tools for a rational approach to evaluation and treatment the next time one of these patients visits your ED.
Cric for the Win
To close out the year, Walker Foland (the orignal Rojo Grande) takes us deep into a surprise critical airway case that exemplifies what we do and who we are.
The Intensivist Strikes Back (at Potassium)
ED intensivist Ran Ran is aggressive when it comes to treating Hyper K. In response to our November 2018 episode 'Evidence Based Hyperkalemia Management', Ran breaks down his steps when the K is high and the patient is deteriorating.
LRINEC and the Accidental D-dimer
Joe Habboushe returns to discuss the nec fasc decision tool- LRINEC. It gets a lot of bad press as being useless, but that might be because we're not thinking about it in the right way. As a bonus, PE wunderkind Jeff Kline goes deep geek on what to do with an accidentally ordered d-dimer that returns elevated.
N of 1 - The Moral Injury of Modern Medicine
Are we calling burnout by the right name? Some would say no, we should call it 'moral injury' because what we see happening in modern medical practice can be antithetical to our core values. In this episode, ZDoggmd is our guest as we examine moral injury, as well as dealing with the EHR, stress, universal health care, meditation, and much more.
EEM 2019: Lessons From the Wound Doc
From Essentials of Emergency Medicine 2019, emergency physician and wound care specialist Matt Delaney reveals his 'One Dressing to Rule Them All' and how he manages patients presenting with skin ulcers.
Patellar Dislocation
Patellar dislocations rarely present a diagnostic or therapeutic challenge in the emergency department. They're almost like the nursemaids elbow of the adolescent and adult knee. But after what appears to be an uncomplicated reduction, patients can face significant complications and may even require surgical repair. In this episode, pediatric orthopedic surgeon Adam Barmada breaks down the pitfalls to watch for, post ED care, and what he's paying attention to when patients see him for follow-up.
ERcast/Essentials of Emergency Medicine 2020 - Fellowship Competition
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.
Bits and Pieces
Our bi-montly session where YOU take the helm with… A poetic ode to CT angiography, consenting stroke patients for thrombolysis, a Reuben Strayer rebuttal to our recent episode on first trimester vaginal bleeding, and Luz Silverio’s rebellion against penicillin allergy.
Kratom, Skittles and Physostigmine
The Dantastic Mr. Tox and Howard (a nickname imbalance if you ask me) are our guests as we talk the ins and outs of Kratom, what Skittles and dextromethorphan have in common, and when you might want to break out the physostigmine.
N of 1 -- Pregame Like a Pro
We can't immediately change the process of medicine, the stuff that is kind of a drag and wears us down. What we can change, however, is our mindset. In this episode, we dissect several practices for shift preparation with a common goal of operating at a peak level of performance and experiencing more joy in what we do.
EEM: STI Updates 2019
I wish this talk were titled "What to do before you discharge that discharge" but alas, it was not to be. From Essentials of Emergency Medicine 2019, infectious disease specialist Greg Moran talks: GC resistance, managing GC in cephalosporin allergic patients, Trich testing, Mycoplasma genitalium, and patient delivered treatment for partners.
Large Vessel Occlusion Strokes
Now that interventional radiology is a viable option for managing large vessel occlusion (LVO) strokes, should we bypass hospitals without IR when patients are suspected of having an LVO? If that's the case, at what point does bypassing a hospital with only thrombolytics in favor of one that can retrieve a clot reach diminishing returns? EMS specialist Bob Zemple breaks down the logistics, evidence, and current thinking.
The DVT That Is, But Isn’t, But Really Is
There are gaps in our knowledge when it comes to DVT management. Simple cases are just that, simple. But the more complexity enters the situation, the more we enter into the unknown, yet still have to make a decision. In this episode, Salim Rezaie gives his approach to filling those gaps.
Open Fracture
Trauma orthopedic surgeon Dr. Derrek Woodbury gives the ins and outs on managing open fractures.
N of 1: Should We Embrace Metrics?
In the modern era of performance analysis and review, metrics are often seen as a tool to punish clinicians. Dr. Sean Dowling says that doesn't have to be the case. We can make metrics work for us and, if they are crafted in a thoughtful way, improve our quality of care.
EEM 2019: Amal Mattu is a Runner who Dislikes Treadmills
From Essentials of Emergency Medicine 2019, Amal Mattu reviews recent evidence on functional cardiac testing in the emergency department and how that fits in to ACEP’s new chest pain guideline
Propofol PAUSE, Incrementalization, and the Wine Glass Intubation
Rich Levitan is known as an airway expert who breaks complex procedures into a series of doable micro steps. In the past, this has applied to things like intubation and cricothyrotomy. Now, Rich sets his sights on propofol procedural sedation.
Bits and Pieces
Pseudogout, massive transfusion, hemarthrosis, syncope, PE, and much more are covered as Matt Delaney joins us to answer your emails, talk about some recent cases, and fill in the gaps on previous episodes. 6.2.6
The Approach to the Active Shooter: Run, Hide, Fight, Treat
Emergency physician, former Special Forces medic, and field trauma expert Mike Shertz walks us through an inside look at active shooter / active violence incidents.
The Salt is Low But the Problem is H2O
ED intensivist Dr. Ran Ran is back to give his strategies for thinking about and managing hyponatremic patients. We learn about beer potomania, the dangers of hydration, when to consider hypertonic saline, and the risk of osmotic demyelination syndrome.
N of 1: Patient Experience
None of us start the day hoping that our patients have a negative experience during the time we care for them. But the medical system, and even some of our habits, can lead to just that. Expert Justin Bright gives his thoughts on how to improve patient experience in the emergency department. His insight may lead not only to improve outcomes for them, but also improved job satisfaction for you.
EEM 2019: About That Cough
From Essentials of Emergency Medicine 2019, pediatric emergency Physician Ilene Claudius gives her rapid fire differential for cough in kids and strategies for treatment. Spoiler alert: over-the-counter cough medicines are deservedly maligned and the better option is honey!
The Subtle Art of Cathing Dudes
Acute urinary retention in a man? No problem! Catheter in, get him a leg bag, and he's on his way with a spring in his step. Unfortunately, that's not always the case. Sometimes these catheters can be a real bear to pass or other odious obstacles make this anything but a simple procedure. In this double header, EM doc Walker Foland and urologist Nora Takla give their tips on catheter passage, potential Foley complications, and the management of clot retention.
Are We Misusing the FAST Exam?
The FAST exam (Focused Assessment with Sonography in Trauma) has been around for decades, but that doesn’t mean it’s without controversy. It was originally intended to determine if an unstable patient should be directed straight to the OR but, since then, there has been indication creep into myriad clinical scenarios. In this episode, we examine the question, “Is there a role for FAST in the stable trauma patient?”
Myasthenia Gravis and Crisis
A myasthenic patient rolls through the door in acute respiratory distress. You think this could be a myasthenic crisis. What’s the next step? Is there something we can do to turn around the situation? To answer these questions (and more), Brit Long returns to ERcast to break down key steps, and missteps, in managing critically ill patients with myasthenia gravis.
N of 1: Digital Minimalism
Our digital lives have become cluttered, scattered, and reflexive rather than intentional. Is it time for a change? In this episode, Rob and ERcast philosopher in residence Dan McCollum, review the principles and exercises laid out in the book Digital Minimalism. Taking it a step further, they share what happened when they went full on guinea pig and dove deep into the process.
EEM: 5 Repeated Narratives That Are Not True
From Essentials of Emergency Medicine 2019, Bouncebacks author Mike Weinstock addresses five things we say (or at least think) and asks, “Is that really true?”
First Trimester Bleeding Controversies
Over the past few years, there have been challenges to many of the long held beliefs about evaluation and treatment of patients with first trimester vaginal bleeding: what is the ideal quantitative HCG discriminatory zone, should we give patients D-immune globulin, what are the next steps when we find a pregnancy of unknown location? In this episode, Cam Berg is back with a multispecialty endorsed decision pathway that addresses all of this (and more!)
Bits and Pieces
Emails, follow-ups, voicemails, and random stuff that has just come up in the past few months including: real world experience with high sensitivity troponin, who should be reading head CTs to rule out subarachnoid, making sense of a new lab test (anti Xa level), a new protocol for opiate withdrawal, the value of ED cardioversion for acute paroxysmal a-fib, and HIV post exposure prophylaxis.
A Burn Surgeon on Burn Management
Burn surgeon Anne Wagner is back to talk burn management, from the most simple to the critically ill. In this episode: the unusual case of admitting sunburn, management of second degree burns, do all third degree burn patients need referral to a burn center, and a simple strategy for fluid resus in large TBSA burn patients.
N of One: The False Assumption of Admitting Errors
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.
EEM 2019: Pediatric Head Injury with Dr. PECARN
The PECARN Pediatric Head Injury/Trauma Algorithm can reduce our use of CTs in peds patients, but it’s often misunderstood (or not even used in the first place). From Essentials of EM 2019, PECARN lead investigator, Nate Kupperman, breaks down how he uses the pathway, limitations, and common misunderstandings. As a bonus, the talk is preceded by REBEL EM’s Salim Rezaie setting the stage with a breakdown of the primary literature.
Peds Fever 2019
Clay Smith from Journal Feed, triple boarded in EM, IM, and Peds, reviews the current literature and practice changes in the evaluation of febrile babies.
Right Ventricular Failure
Managing acute left ventricular failure can seem like the nursemaids elbow of the resus room, but the failing RV is a different story. Intensivist Haney Mallemat argues why the RV is unique and how to treat it with respect (and not get burned) in the criticall in patient.
Did I Just Diagnose Diabetes?
It’s rare for a shift to pass without seeing a lab value return with hyperglycemia (in a non-diabetic). So, does that patient actually have diabetes? Our guest, internist Neda Frayha, dissects what happens next when the patient leaves the ED and that question is answered. There are also tips on starting oral hypoglycemics when it’s clear there’s newly diagnosed DM, deciphering the A1C, and demystifying insulin.
Personality Disorders
From the second you walked into the patient’s room, you could tell something was not quite right. No matter what you say or do, things seem to be going in a negative spiral and you can’t figure out why your usual charm isn’t working. The issue at hand may be a personality disorder (the patient’s, not yours). In this episode, psychiatrist Shawn Hersevoort breaks down the different types of personality disorders and how to approach patients with them.
N of One: Closing Time -- Finishing Your Talk Like a Pro
Pediatric surgeon Ross Fisher, the mind behind P Cubed presentations, breaks down how to finish a talk (teaser, it’s not a random vacation slide or you saying, “Thank you,” and walking off stage). As a bonus, he also discusses structuring a lecture with spaced repetition so your audience truly understands your message.
EEM: Should We Reverse Antiplatelet Agents?
A patient with an acute brain bleed is also on aspirin and clopidogrel - should we infuse platelets to reverse the effects of these agents? From Essentials of Emergency Medicine 2017, Scott Weingart reviews the evidence and gives a simple algorithm.
Too Fake
It’s 3am, and your next 5 patients have dental pain. The first three have normal appearing teeth, the fourth a little swelling on the gum next to the canine and the third a grossly swollen face. What do to? Our disambiguator, Adam Rowh, breaks down the evidence and a rational clinical approach.
Bias, Chest Tubes, and Listener Mail
Mizuho Morrison and Rob talk about overcoming cognitive errors during a busy shift, discuss a recent paper about which traumatic pneumothoraces may not need a chest tube, answer listener emails, and debate the proper pronunciation of smörgåsbord.
Circling the Drain
Scott Weingart and Amal Mattu are our guests as we breakdown the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.
N of One: Aim to be a Zero
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.
Did Canada Crack the Syncope Code?
Figuring out a decision tool or even consistent clinical approach to syncope has been like finding peace in the Middle East. Lots of people thought that they have had the answer but, let's face it, they haven't. Now, a research team from Canada may have found the right formula for emergency department evaluation: using a combination of the Canadian Syncope Risk Score and a few hours of cardiac monitoring.
EEM: Sentinel Injuries - Is This Child Abuse?
From Essentials of Emergency Medicine 2018, Ilene Claudius breaks down the clinical clues that the child in front of you may have suffered non accidental trauma.
D-Dimer Confusion
In this episode, we answer a listener question on utility of D-dimer in patients with intermediate risk, or intermediate Wells score, for pulmonary embolism.
The PEEP Show
ED intensivist Dr. Ran Ran walks us through what PEEP is, what PEEP isn't, and how to apply that to the critically ill.
N of One: Why and How to Take a Break During Your Shift
The thought of taking a break during a busy emergency department shift can sound impossible if not contrary to the ethos of our job. The reality, however, is that taking a break is not only possible, but will likely make you clinically sharper, more efficient, and possibly even happier. In this episode, Dr. Joshua Russell walks us through how to take a break within the constraints of our clinical responsibilities as well as pitfalls to avoid when taking a pause from patient care.
EEM: Avoiding the EMTALA Police
From Essentials of Emergency Medicine 2017, Corey Slovis and Sanjay Arora break down what's required of us in the ED regarding EMTALA, as well as what happens behind the scenes when there is a violation.
Infected and Obstructing Nephrolithiasis
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.
A Child With Acute Airway Swelling
A child presents with acute airway swelling and is heading toward extremis. What’s the next step? In this case based episode, we break down evaluation and management of pediatric and adult patients with acute angioedema.
Are Some Moderate Risk Chest Pain Patients Actually Low Risk?
The HEART score is now well accepted as a decision instrument in determining what chest pain patients are low-risk. New data suggest that higher score patients may actually be much lower risk than previously thought. Dr. Adam Sharp, lead author of a recent JACC study, explains why his data on almost 30,000 ED patients may reshape our thinking on low-risk chest pain.
Damage Control Resuscitation
Canadian trauma team leader Andrew Petrosoniak is back to break down strategies in trauma resus including: CPR and critical actions in trauma arrest, why we should show more love to fibrinogen, the importance of remembering calcium, prioritizing hemostasis over resuscitation, and how to simplify transfusion decisions.
N of One: Bouncing Back After a Tough Case
The nature of emergency medicine dictates that we will have tough cases. Patients will die, we will have to deliver bad news, and we will, at some point, make mistakes. We have high expectations of ourselves so when we get figuratively knocked down, how do we get back up? In this episode, performance coach Jason Brooks guides us through strategies for dealing with the emotional and intellectual fallout of a bad case as well as how to re-engage during a shift when the last thing we feel like doing is seeing the next patient.
EEM: How to Use the Pulse Ox Like a Boss
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.
Clogged and Dislodged: A Guide to PEG Tube Badassery
We may not place PEG tubes but we certainly encounter their complications. From blockages to dislodgement, PEG issues are a frequent occurrence in the emergency department. In this episode, we get perspectives from emergency physician Walker Foland, as well as gastroenterologist Mike Phillips, on troubleshooting and managing the misbehaving G-tube.
Abdominal Stab Wounds: The WTA Algorithm
When a patient presents with an abdominal stab wound and there are intestines coming out of the hole, it’s no great mystery as to what’s going on. But what about the equivocal case where the patient has a small puncture and is relatively well appearing? Image, observe, explore the wound? In this episode, Clay Smith from Journal Feed walks us through a recently published guideline on how to evaluate patients stabbed in the abdomen that addresses this and pretty much every other stabby abdominal scenario.
Adrenal Crisis
The adrenal glands do a lot of important jobs including production of cortisol, aldosterone, epinephrine, and norepinephrine. But how well do you really understand these tiny glandular powerhouses? Emergency physician Bob Zemple walks us through some adrenal basics as well as how to recognize and manage patients in adrenal crisis.
N of One: Life, Death, and Medicine
Christiaan Maurer, a Colorado internist and hospitalist recently diagnosed with glioblastoma, reflects on life, medicine, and what’s important.
EEM: Post-Tonsillectomy Bleeding
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.
The PE Bounceback
When a patient with a known and treated pulmonary embolism returns to the ED with increased pain or shortness of breath, what’s the next step? There is no textbook answer for this one, so we reached out to the PE expert, Jeff Kline, to give his approach.
Flu: Test and Treat. Or Not.
How one approaches and manages influenza is part science and part preferred practice style. Today’s podcast presents AK’s interpretation of the literature and how she manages patients during a shift. As you will see, AK is a testing and treatment minimalist.
Perfectionism, EQ, Middle Way
What does the former CFO of Pixar have to do with physician burnout and the culture of medicine? We find out in this segment. Neda Frayha from Primary Care RAP interviews Dr. Todd Cassese and Lawrence Levy, who helped build Pixar into the company it is today. Together they talk about changing professional cultures, the narrative of medicine being out of sync with the reality of medicine, perfectionism, emotional intelligence, and how Eastern philosophy’s The Middle Way can apply to all of our lives.
EEM: Can You Fix Asystole?
There is a dearth of evidence guiding our management of asystole. At Essentials of emergency medicine 2018, Anand Swaminathan gave his approach to managing this rhythmless dysrhythmia, bridging the gap between acting just to act, and acting with intent to save.
Frostbite
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.
Strokes, Stones, and Standing in Feces
In this episode we discuss: Should we use TPA in patients with non disabling, low NIH score strokes? A massive study on POCUS for suspected ureteral colic, and some surprising recommendations in the recent ACEP Clinical Policy on acute thromboembolic disease.