July 31, 2020
The short answer is not at the moment, but that hasn't stopped the debate (and surprising culture war) from raging about this drug. We discuss: Evidence supporting use of HCQ Evidence against using HCQ Why wearing a mask with your nose out is like wearing your underwear with, well, not everything covered
July 27, 2020
When we hear the word stoic, what often comes to mind is a repression of emotion, a stone-faced response to adversity. You can think of that kind of stoicism as using it with a lowercase 's'. What we're talking about today is the philosophical school of Stoicism, Stoic with a capital 'S'. At its core, Stoicism provides a way to find equanimity no matter the circumstance and take on whatever adversity is thrown at you.
July 16, 2020
How long does immunity last after a COVID infection? News reports of two recent studies suggest that it wanes quickly and that some patients may never have immunity at all. In this episode, we take a look at those studies and explain why they don't exactly say what is being said about them.
July 9, 2020
Performance coach Jason Brooks breaks down how to achieve flow state and retrive it when it's lost.
June 29, 2020
Our guest today is Dr. Zubin Damania (aka ZDoggMD), an internist, hospitalist, and healthcare evangelist. ZDogg is dedicated to turning the practice of medicine into the healing art that it should be, rather than the leviathan of bureaucracy, roadblocks, and nonsense that it sometimes seems to be. In this episode we cover:  the morality of masks and not wearing them in public, racism, suspension of the scientific method in the early phases of the pandemic, Star Wars, and much more.
June 11, 2020
In this episode of Stimulus, we speak with Christina Shenvi MD, PhD about acting with agency -- what it means, some actionable skills, and how to apply it. We also talk about:  the importance of being specific and deliberate about your philosophy of life, how remembering your mortality puts the rest of life in perspective, Stoic philosophy, Viktor Frankl, and whether or not we have free will.
June 8, 2020
In this swan song of ERcast Lite, we speak with Scott Weingart about the truths, misunderstandings, and physiology of ECMO.
June 2, 2020
Emergency cardiology guru Amal Mattu on the many different ways COVID-19 can attack the heart.
May 25, 2020
When you work in an environment where there is a paucity of natural break opportunities or an ethos and cultural expectation that you should just power through, you need to make a habit to ensure that the break happens. 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.
May 18, 2020
In this episode, we learn from two masters in the art of de-escalating those who are agitated and upset.
May 14, 2020
Bob Ross has a lot to teach about how to be excellent in the trauma bay.
May 7, 2020
Jim Dahle, AKA The White Coat Investor, gives perspectives and strategies on managing finances during a bear market.
April 30, 2020
None of us are immune from stress, especially now. This is a critical moment for us to look out not only for our own mental health but that of our colleagues.
April 30, 2020
None of us are immune from stress, especially now. This is a critical moment for us to look out not only for our own mental health but that of our colleagues.
April 23, 2020
Breathwork coach Ryan Cheney walks us through exercises to make breath work for us, not just with us.
April 22, 2020
A critical care crash course with Mizuho Morrison and Scott Weingart.
April 17, 2020
Don't just suck it up. Think differently.
April 17, 2020
Don't just suck it up. Think differently.
April 13, 2020
Hematologist Tom Deloughery gives a primer on COVID-19 cytokine storm, d-dimer, DIC that leans toward thrombus, why some clots break through heparin, utility of low molecular weight heparin, and using TPA for ARDS (don’t get too excited on that one quite yet).
April 9, 2020
ED-intensivist Scott Weingart has developed several protocols for airway management in COVID-19 patients, but each of those answers brings up more questions. In this episode: ‘happy hypoxemia’, the 4 types of COVID patients, Covid L vs H, is there a role for ECMO in severe disease, why intubation should be a last resort, the importance of patient positioning, and much more.
April 5, 2020
In this episode we speak with Chris Hicks, Canadian emergency physician and trauma team leader who is a master of teaching the cognitive skills of resuscitation.  Chris shares several protocols from his hospital regarding code blue and intubation in the era of COVID-19 including.
April 2, 2020
In today’s update: New York experience with fluid restriction in COVID ARDS, prone positioning for non-intubated hypoxic patients, resetting the intubation threshold, and using ABGs. Your questions for Reuben Strayer and Patrick Reinfried. For all the previous COVID podcasts plus a bunch of other super useful stuff, here is our depository of resources.
March 28, 2020
Triage and treatment tents have become ubiquitous in the current pandemic, improving throughput and keeping infectious but relatively well patients outside of the hospital. In this episode, emergency physician Josh Bucher, assistant professor at the Robert Wood Johnson Medical School, breaks down how his team has set up and uses their tent.
March 25, 2020
In this episode I speak with Dr. Reuben Strayer, emergency physician at Maimonides Medical Center in Brooklyn, NY. The news is rife with reports of New York’s escalating COVID-19 cases and there are lessons we can learn from how they are responding.
March 21, 2020
Kirkland, Washington was the first U.S. city with reports of a large-scale COVID-19 outbreak. In this special edition of ERcast, Dr. Patrick Reinfried, an emergency physician practicing at Kirkland’s Evergreen Hospital, gives a first hand account of what happened in his community, how his hospital has responded, and lessons learned.
March 19, 2020
In this episode I speak with Dr. Rick Pescatore, Chief Physician for Preparedness for the state of Delaware and a front-line emergency physician.  While the general topic is the COVID-19 pandemic, specific issues discussed include: triage decisions, X-rays, troponin, what to do when there’s limited testing ability, antibiotics, chloroquine, viable strategies for managing homeless populations, and more.
March 18, 2020
In today's episode, emergency physicians Amy Cho and Jason Adler break down novel ways to limit use of PPE while at the same time minimizing contact with potentially infected patients, how regulations have obstructed our ability to provide intelligent but are now are starting to relax, a few seconds on washing your gloves,  how do you respond when a coded patient is coding (more of a question than an answer in this conversation), and what key moves for leadership that can make an impact.
March 12, 2020
This episode launches Stimulus. My new podcast that deconstructs strategies to live and practice with intent. Don't just suck it up, think differently.  Website: Itunes: Link Spotify: Link Stitcher: Link
March 12, 2020
Dan Bissell, MD is co-founder of Portland Street Medicine, a medically focused non-profit dedicated to caring for the homeless. What’s unique about the care delivered is that it happens in the austere environment of homeless camps, underpasses, and street corners. In this episode, Dan and I cover what a day of the street medicine team looks like, how his group started, and how street care has impacted his everyday medical practice.
March 12, 2020
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. Today we learn how to pregame, like a pro.
March 12, 2020
We learn from two masters in the art of de-escalating those who are agitated and upset.  Jose Pacheco, RN,, known affectionately to his co-workers as ‘The Drunk Whisperer’, and Dan McCollum, MD, who approaches conflict resolution with the martial arts principal of using your opponent's energy to resolve conflict, rather than simply butting heads. The name for this method? Verbal Judo.
March 1, 2020
Regardless of your job title or description - doctor, nurse, EMS, fire, police, 911 operator, you get thrown into the fray with a basic set of medical skills, but little on HOW to REALLY do it. The skills to thrive beyond managing disease or living up to the title on your ID badge.  That is what motivates this show, what you will find here. Walking through and deconstructing strategies to live and practice with intent. To not waste our time. And to tap into the joy of what we do.
January 30, 2020
What we know so far about the new 2019-n-CoV coronavirus outbreak and what front-line clinicians can do if we suspect a patient of ours might have this viral illness.  Infectious Diseases specialist Dr. Devang Patel sits down with our good friend Dr. Neda Frayha to discuss.
January 30, 2020
In this 10th anniversary special, GFOP Josh Russell interviews Rob and digs deep into... Failing at work Finding the right job (and being honest about the wrong one) Top Gun Origins of ERcast Why Rectal Foreign Bodies was the subject of episode one Advice for young doctors How failing a black belt test was a pivotal moment Guiding principles Memento Mori This pod contains absolutely no clinical medical education. There is no CME attached to it.
December 20, 2019
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.
November 30, 2019
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'.
November 6, 2019
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.   APPLY NOW: ERcast’s 2020 Audio Podcast Competition for Essentials of Emergency Medicine Education Fellowship Program     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. EEM Education Fellowship EEM is offering ERcast a mini-fellowship position to eligible residents anywhere in the world. Those selected to participate will receive: FREE conference registration FREE 4-night hotel stay at the Hilton Union Square, San Francisco, CA A travel stipend of US $500 As part of the EEM staff, fellows will get a rare opportunity to experience the behind-the-scenes work associated with developing and producing one of the world’s largest and best EM educational conferences. Fellow responsibilities will include online chat moderation, social media management, CME preparation, research projects, and more. A common theme voiced by previous EEM fellows has been the opportunity to interact directly and develop meaningful relationships with the renowned, fun, and master clinician-educators in the EEM faculty. Quotes from the 2019 EEM Fellows: “This fellowship was more than just a chance to attend and work at a phenomenal educational conference. It gave me the opportunity to meet and work alongside other amazing residents and faculty that I don't think I would have crossed paths with this early in my career otherwise. What this fellowship really played out to be though was an invaluable networking opportunity with giants in the field of Emergency Medicine. I established mentors, I curated friendships and most importantly, changed my mindset of what medical education has to look like in the absolute best way possible. Not only would I work this conference again and again, I will be in attendance for it every year I can be. Paul and his team changed the game of what traditional ‘continuing medical education’ has to look like and it was a privilege to sit front row to witness and learn from it.” -Michelle Romeo, MD   “Without a doubt, the most fun you’ll have at a conference, ever. EEM is what all conferences should be- high-yield, exciting, fun, pinpoint educational pearls with a one-of-a-kind ambiance of comradery, fellowship, and shared experience... Essentials is truly something very special. It is hard to explain to my friends how exciting, educational, AND entertaining this conference is! I returned to my work with a renewed love for my specialty, my patients, and my colleagues. See you next year!” –Tim Montrief, MD, MPH   Application Process We at ERcast are launching this contest for interested applicants in conjunction with Dr. Michelle Lin at ALiEM. What’s the primary difference between the two contests? ERcast’s contest involves creating an audio podcast submission while ALiEM’s contest involves writing a blog post. Complete the application form below and submit a 1-minute audio submission on anything clinically or educationally relevant to EM providers. Be creative, showcase your educational prowess, and teach us something about a topic you are passionate about!  All applicants must be in good standing at an ACGME-accredited Emergency Medicine program in the United States, or in good academic standing at any Emergency Medicine residency program in the world, and be available to attend all 3 conference days of Essentials of EM in San Francisco May 21-23, 2020. Applicants should complete a brief online application and upload material through the online form below. The application process is open now. Judging Criteria Your audio submission (< 60 seconds) will be judged on: Relevance (How relevant is this submission to EM education and/or clinical practice?) Innovation (How creative and innovative is this submission?) Design (How well is the information presented and delivered?) Content (How well did this candidate present the material with respect to clarity, conciseness, accuracy, references?) Important Dates Deadline for submissions: January 15, 2020 at 11:59 pm PST Fellowship winner announcement: January 31, 2020 Questions? Email us. Ready to Submit Your Application? Checklist: Your post-graduate year of training Your EM residency program name, program director’s name, and his/her email  Your email address Your audio file (please submit in mp3, m4a, or wav format)  Go to Application Submission Site
October 3, 2019
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.
August 27, 2019
Keynote from Essentials of Emergency Medicine 2019
August 25, 2019
In this episode we discuss the elements of documenting a patient's decision-making capacity, pearls from the last month of ERcast, our new newsletter, and Carl Sagan's Pale Blue Dot.
July 6, 2019
Scott Weingart and Amal Mattu are our guests as we break down the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock. Want weekly episodes, world class show notes, CME, and a super sweet app? Go to and subscribe to the whole kit and caboodle.
April 13, 2019
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. Subscribe and hear the rest of the show.  CLICK HERE! For access to more incredible education and 2.25 hours of CME each month. 
March 11, 2019
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.
February 11, 2019
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.
January 7, 2019
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.
December 2, 2018
A consensus summit with world experts and primary researchers focused on the question, “After a negative ED evaluation for ACS, is an expedited outpatient evaluation a safe alternative to admission?” Featuring Colin Kaide, MD, Mike Palacci, MD, Barbara Backus, MD, Erik Hess, MD, Ezra Amsterdam, MD, Douglas Van Fossen, MD, Rob Orman, MD, Mike Weinstock, MD, and Cam Berg, MD
November 7, 2018
Hyperkalemia is one of, if not the most, common electrolyte abnormalities we see. But much of what we do in treatment is what someone told us to do when we were young learners. In this episode we debunk hyperkalemia myths and discuss an evidence based approach to management. For more great content check out
November 1, 2018
Cory Slovis, MD from Essentials of EM 2016 breaking down when to call a prehospital code, and when to keep the resus going.Check it out
October 8, 2018
A first hand account of the emergency department response to the 2017 Las Vegas strip shooting that left 59 dead and over 800 wounded. Discussion of preparation with 20 minutes warning, how to keep patients flowing as they enter the hospital as well as once they’re in the treatment area, effective triage, critical steps to simultaneously resuscitating large numbers of trauma patients.
September 4, 2018
Britt Long, MD and Rob Orman, MD discuss emergency department management of patients with complications of cirrhosis.
August 6, 2018
Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy.  Asthma is different than other causes of severe respiratory distress.  And there are different forms of asthma as well. Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case? Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management. In the rare cases of severe asthma with a ‘stone chest’ that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible.  It’s the only way to safely provide the airway pressures you need. Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration. Failed attempts at intubation are especially risky in these patients.  As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.
July 1, 2018
The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.   20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed.  Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission. Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate.  Also, amongst the survivors, the neurologic outcome was worse. Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful. The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period.  These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.
June 3, 2018
Internist Neda Freyha sprinkles some IM in the ED - how to interpret TSH levels and why aspirin is no longer recommended for a-fib thromboprophylaxis.
May 4, 2018
Rob and Tom Deloughery discuss management of actively bleeding patients who have been prescribed anticoagulation medications.
April 30, 2018
Unlike most guests on this show, Joe Polish is not involved in medicine- he is one of the best known marketing minds on the planet. He is the creator of the Genius Network, best selling author and renown podcaster. But none of those things are why Joe is on the show today. Joe is also an addict, but deeper than that, he’s turning his experience with addiction into a force for change with Genius Recovery and Artists for Addicts
April 24, 2018
In this interview we cover a wide range of topics including Underwear How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist Meditation The Mind Illuminated The roots of anxiety Mental preparation before giving a talk ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement Nurse practitioners
April 17, 2018
Metronidazole is no longer recommended as first line for mild C Diff infection
March 21, 2018
In this episode, we down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.
March 12, 2018
Joe Habbousche is the CEO of MDCalc, the world's most used online medical calculator. Chances are, you've used it yourself. Joe is a passionate advocate for the practice of evidence based medicine and the proper use of clinical decision tools. In this episode, we dissect one of his favorites: the Canadian CT Head Injury/Trauma Rule
March 5, 2018
In the edition of the Ercast journal club thrombectomy in pts with delayed stroke presentation shows promise beware behavioral changes after procedural sedation kids with isolated linear skull fractures have a good short term prognosis procalcitonin may help decrease abx use in respiratory infections steroids in mild sore throat help... a little
February 26, 2018
Amal Mattu gives his thoughts on why we actually get sued for missed MI. Is it the patient who has an impeccable workup and shared decision making? Or are there other factors/patient characteristics that commonly show up in lawsuits?
February 18, 2018
Are more opioids the answer when a chronic pain patient (on opioids) presents with acute pain? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.
February 11, 2018
Strategies on what to do when the consultant on the other end of the phone call is giving questionable advice (or perhaps just being rude)
February 5, 2018
Anorexia is often viewed as a chronic condition that doesn't really warrant emergency care, but that's not the case. Mortality with anorexia nervosa is high -on the order of 10-20%
January 29, 2018
Recorded at Essentials of Emergency Medicine 2017, Greg Moran MD reviews current thinking on cellulitis diagnosis and management
January 22, 2018
Performance coach Jason Brooks PhD gives his strategies and tactics on myriad topics including: three techniques for stress inoculation, improving test taking, the unseen costs of hiding ignorance, and what habits are common among high level performers.
January 15, 2018
Should I give bicarbonate to DKA patients with severe acidemia? I've certainly been admonished for NOT doing it. The reason for withholding bicarb has been that I've heard that it doesn't help and may actually be a bad idea. I can't say the action (or inaction) was based on a deep understanding.
December 12, 2017
The White Coat Investor
December 8, 2017
What  gives you fulfillment in your job? If you know it, do you make purposeful choices to keep pointed in that direction?
December 6, 2017
Little things can make a big difference when it comes to running a code. EMS director and CPR aficionado Bill Reed gives a primer on High Performance CPR.
November 27, 2017
-When is showering OK after stitches? -What type of ointment should be placed on a laceration to promote healing? -Is there an advantage to using antibiotic ointment over petroleum jelly on a non infected laceration? -How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon? -What type suture to use for extensor tendon repair.
November 23, 2017
A simple exercise to improve resilience. At the end of each day, ask yourself: what are the three things that went well today and what was your role in bringing them about?
November 20, 2017
Medical facilities are challenging for someone with autism. This episode reviews 7 ways to improve the experience for pts, families, and medical providers
November 13, 2017
Ashley Leibig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.
November 6, 2017
Rapid treatment and life saving tools in the management of junctional bleeding: Bleeding from an area that is a junction of an extremity and the torso (and neck) that is not amenable to hemorrhage control by tourniquet.
October 30, 2017
What is your real motivation when making medical decisions? Is it 'what's in the patient's best interest' or is it  'what will keep me from getting sued'? The reflexive answer is, of course,  the former, but if you really do some soul-searching, there's probably a bit of the latter as well. In this episode, Mike Weinstock, author of Bouncebacks, and Bouncebacks Pediatrics, discusses why we sometimes have our priorities misaligned with the patient's and how that doesn't need to be the case.
October 23, 2017
Have you ever watched a volleyball game and seen the ball fall between two players? What happened there? It was probably inadequate or insufficient communication as to who was going to make the play. The same thing happens in almost every professional arena: mistakes are made because of poor communication. In this episode we discuss three tools to improve how we relay information to each other, eliminate ambiguity, and the biggest goal of all - improve patient safety.
October 20, 2017
Our periodic journal club is back with discussion on... Cervical spine clearance in the intoxicated patient (can you remove the collar if they have a negative CT?). Is there utility to giving antibiotics to patients with simple cutaneous abscess?. Thrombolytics don't give long term benefit to patients with submissive pulmonary embolism. Haloperidol is good for what ails you (if you have gastroparesis). Steroids for bronchitis
September 30, 2017
Megan Spyres, toxicologist and emergency physician at LA County-USC, gives a primer on diagnosing and treating Wernicke's encephalopathy. The title of this post "What you don't know about Wernicke's encephalopathy" is more from my perspective than a commentary on what you, the listener, may know. After all, you might be a genius when it comes to this disease. For me, this has always been confusing and difficult to diagnose.
September 20, 2017
Ultrasound legend and newly minted community ED doc Mike Mallin drops into the studio to talk abscess ultrasound, placing IVs, night shifts, and handoffs.
July 25, 2017
This is not an easy episode. It's not easy because a doctor gets named in a lawsuit, a patient has a bad outcome, and it openly discusses some of the systems failures we have in medicine. If that's enough to turn you off, close the page and go about your day. You'll probably be happier for it.  Still here? Well, here's what we've got... Cam Berg is arguably one of the brightest stars in emergency medicine (or all of medicine if you ask me.) Even that level of excellence, however, didn't stop Cam from being named in a lawsuit when a patient had a catastrophic outcome. This case involves a series of events that include: hypertension, IV hydralazine for asymptomatic hypertension, boarded patients, stroke, thrombolytics, brain bleeds, and the collateral effects of getting sued.
July 2, 2017
Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer. Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised.  Stuff Adam and Rob have discovered recently and are really digging Rob Dermastent Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls of heavenly delight I use during shifts (and home, and exercise, and so on).  This Tono-Pen Adam Wearing gloves while eating a sandwich Topical TXA for a persistently bleeding biopsy site in a patient taking rivaroxaban Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in the nebulizer basin either with or without bronchodilator Treating Priapism Patient presents with persistent painful penile erection. Anesthetize the penis, sterilize the area of corpus cavernosum you are going to drain. How one numbs the penis for this procedure is a matter of great debate, meaning there is no best answer. Some espouse a dorsal penile nerve block while others favor local anesthesia at the site of injection. I prefer local infiltration at the site of injection and have found it to be more reliable than trying to get the whole penis numb. Mix up a solution of dilute phenylephrine. This is your vasoconstrictive agent. The end goal is to dilute 1mg of pheynylephrine with 10 mL of normal saline (or 9.9 mL if you're a purist). This gives a concentration of 100mcg/mL ( the recommended dose from the American Urologic Association is actually 100-500mcg/mL, giving a significant margin of error). The phenylephrine you have in your department is most likely 10mg/mL, so you will end up drawing a tenth of a mL.  Getting the vasoconstrictive agent mixture correct seems to be one of the more anxiety provoking aspects of this procedure.  There are lots of ways to make your mixture, the most straightforward method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB syringe. Into that same syringe, draw up 0.9cc of saline. Now you have a total of 1cc total volume. Add that to 9cc of saline and you are at the desired 100mcg/mL concentration. When you've got this task completed, set this syringe to the side. You're going to need it shortly. Pro tip: label the syringe after creating the dilute phenylephrine. Attach an 18 or 19 g butterfly needle to a large syringe Inset the butterfly needle into the corpus cavernousum at the lateral base of the penis. It doesn't matter which side, each side connects to the other. Your entry point is either 10 or 2 o'clock. Pull back on the syringe while advancing the needle. Once you get blood back, stop- that is your needle depth for the remainder of the procedure. Pro tip: Even though you might be tempted to use the biggest syringe you can find, like a 60cc behemoth, stick with a 20cc syringe. The bigger syringe might create too much suction, which can ruin the day. Aspirate blood. This will look thick and dark (chocolate syrup, old motor oil dark). The amount you'll be able to aspirate varies, but it's usually  around 10-20cc. Keep the butterfly needle in place while you  unscrew the aspiration syringe from the proximal port and replace it with your syringe with dilute pheynlephrine. Better yet, use a 3 way stopcock. On one port, you have your vasoconstrictive agent ready to go. On the other port, you can easily work the replacement of fresh aspiration syringes. Having an assistant for syringe management makes this process much easier (and safer as you're less likely to change the position/depth of the butterfly needle while fiddling about with the syringes) Inject 1mL of dilute phenylephrine into the penis. Pro tip that's probably not actually a pro tip: After injection, massage the penile shaft to get more diffuse spread of the vasoconstrictive agent. Does this massaging actually improve outcome? Unknown. The penis may now become flaccid or it may still be tumescent. If the erection does not resolve, repeat steps 6 through 8. This may take several rounds of aspiration and injection of vasoconstrictive agent. When is the penis flaccid enough that you can stop? Some say when the blood aspirated, others when the penis stays flaccid. There's not an absolute demarcation line, it's more of Justice Potter Stewart's "I know it when I see it." Milk the penis from tip to base to squeeze out residual blood. The patient can do this as well. Pro tip: After you've finished the above steps, wrap the penis in a compressive bandage like an ace wrap or Coban to prevent reaccumulation of blood. If you are unable to resolve the priapism with this technique, urology may need to take the patient to the OR Hematuria When a patient presents with hematuria, what are the key questions to ask in the ED? Is there any associated pain? If so, you may be dealing with a stone, infection, etc. If it is painless, which is the most common situation we see, the big question is whether or not the patient is in CLOT RETENTION. Are they retaining urine or can they pee freely? The test for this is a post void residual bladder scan If they are peeing blood, but not in clot retention, they can follow up with urology as an outpatient for CT urogram, cystourethrotgam, and advanced urine testing If they are in CLOT RETENTION, you need to drain the bladder. What often gets placed is a three way catheter. These catheters are great for irrigating the bladder, but may not be sufficient to evacuate clots. Dr. Shaffer recommends placing a 22 Fr 6 eye catheter. Here's an example of a 6 eye catheter (we have no connection with the company selling these in the link provided) Once the 6 eye catheter is in, hand irrigate the bladder until there are no clots If the urine clears (cranberry colored or lighter), pull the catheter and give a voiding trial If the urine is still bloody, NOW place a 3 way catheter and admit the patient for continuous bladder irrigation. They get admitted to see if they go back into clot retention. Jess Mason and urologist Eamonn Bahnson have a master class review of placing the difficult foley in the August 2017 edition of EMRAP. Interstitial cystitis Evaluate for and treat infection Manage pain Make sure they're on an anticholinergic Follow up with urology  
June 24, 2017
Last summer I took a road trip to Canada and during the drive I listened to the book When Breath Becomes Air. That was a year ago, and I still think about that book, almost daily. When Breath Becomes Air is the autobiographical account of the final 2 years of neurosurgeon Paul Kalanithi life. Paul was in residency, age 36,  when he was diagnosed with stage 4 lung cancer, to which he ultimately succumbed. The book tells the tale of the nuts and bolts of his treatment, his transformation from doctor to patient, but more importantly, it was about time. His time was limited, just like all our time is limited, but with a terminal diagnosis, in the face of death, he asked the question, “What makes life worth living?” What do you do with your time, what’s important? Do you work if you’re physically able, do you spend all of your remaining time with your family? Time can feel infinite, especially when you’re young, but as individuals, time is our most precious resource, and it’s a nonrenewable resource. So how do you spend it? Paul died before completing his manuscript and his wife, Lucy Kalanithi, a Stanford internist, put it together and wrote the epilogue. Since then, she’s become a passionate a vocal advocate for helping others choose the heath care and end of life experiences that best align with their values.  In May 2017, at Essentials of Emergency Medicine in Las Vegas, I sat down with Lucy for a live interview on why she does what she does, some of the experiences she and Paul when through, how her perspectives on life and medicine have changed, what she thinks when she sees a patient with the sniffles, what if everyone died like a doctor, and reframing the question where there is a devastating diagnosis or even a run of bad luck from, “Why me?” to “Why not me?” I’d encourage you to listen to this particular podcast episode all the way through and not in small chunks. It builds momentum as the conversation progresses and at the end, culminates in what are some beautiful words of wisdom...Life is not about avoiding suffering.
June 21, 2017
It may be summer (in the northern hemisphere), but that doesn't mean we can talk all the goodness that was our spring journal club. As usual, Adam Rowh slayed the beer selection with a killer Scottish ale as well as these lovely articles. Enjoy.... The papers Less is more for low back pain Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530. Full article link   How worried should you (and the patient) be about discharge glucose? Driver, Brian E., et al. "Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia." Annals of emergency medicine 68.6 (2016): 697-705. Full article link   Ibuprofen and fracture healing DePeter, Kerrin C., et al. "Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?." The Journal of emergency medicine 52.4 (2017): 426-432. Full article link via Broome Australia's favorite ginger raconteur, Casey Parker   Ketorolac's therapeutic ceiling Motov, Sergey, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial." Annals of Emergency Medicine (2016). Full article link from, yep, once again, Casey Parker   Concussion, Rest, and the 8th Dimension Grool, Anne M., et al. "Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents." Jama 316.23 (2016): 2504-2514. Full article link Thomas, Danny George, et al. "Benefits of strict rest after acute concussion: a randomized controlled trial." Pediatrics (2015): peds-2014. Full article link
March 24, 2017
Amal Mattu stops by to talk about the best way to get the most from attending (as well as giving) a lecture. Hint, it's not the the transfer of information. Amal says that lectures have one of two purposes: to persuade or  inspire. To get the most out of attending a lecture take notes no more than three take home points per talk when you get back home, review your notes and read the handout, source material, etc ask questions if possible do not sit passively and try to absorb information by some sort of osmotic wizardry To get the most out of giving a lecture simple slides without too much or complex information no more than one take home point every 10 minutes engage the audience in the discussion repeatedly reinforce the take home points practice and then practice a bit more   Links discussed in this show P Cubed Presentations Link Essentials of Emergency Medicine Link Confound definition
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