A short, focused discussion of emergency medicine topics with perspectives from emergency physicians as well as other specialties. Here's the problem: When I listen to a 45 minute lecture that goes through about 15 different studies and has 50 slides, I come out feeling like a genius. An hour later, I have forgotten 95% of it. Here's the solution: ercast. We cover a single issue and try to tease out all the relevant elements without overstuffing your frontal cortex. It's for physicians and anyone interested in a bare bones look at emergency care.
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.
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 ercast.org and subscribe to the whole kit and caboodle.
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.
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.
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.
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
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
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.
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.
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.
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
In this interview we cover a wide range of topics including
How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist
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
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
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
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?
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.
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.
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.
-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.
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.
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.
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.
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.
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
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.
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.
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
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.
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
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