ERCAST
current issues in emergency medicine, reviews, opinion and curbside consults

It is bronchiolitis season my friends. Even I have a bit of the URI. When we’re talking bronchiolitis, the conversation is almost always about: do steroids or bronchodilators work, what to do with a touch of hypoxia. Important conversations to be sure, but the highest yield pearl I have ever received about bronchiolitis (or any pediatric URI for that matter) was given to me by pediatric emergency physician Andy Sloas. Wash it out, suck it out. 

 

We know that babies are obligate nose breathers. When that nose is plugged, breathing is harder and they don’t eat. When they don’t eat, they get sicker. They cycle continues until they get dehydrated and REALLY sick.

Sometimes a baby with a stuffy nose who isn't eating just needs a little nasal clean out. They breathe easier, they start to eat, or drink (which is usually the case) and often can go home without any other treatment.

So if a child has a URI with a runny nose and isn’t feeding, squirt in some saline and suction out the boogers. The key is in the home care. Most parents will tell you that they’re suctioning with the little bulb suction, but they can benefit from a structured approach.

Home care

How often to suction?

Breakfast, lunch, dinner and right before bed. 

Saline drops

Before suctioning, squirt in some saline drops. You can give the parents some drops or they can buy them from the pharmacy. 

Squirt in the saline drops. The child might cough. They might cough, swallow mucus, and vomit after some saline drops. All that nasal goo getting swallowed can make kids vomit, and that’s expected. Not desirable, but it happens. First saline drops, then suction. The parents might not be able to get mucous with each suction and that’s OK. It’s the repeated attention that matters.

Here is an example of a discharge instruction for runny nose treatment. 

To help clear nasal secretions (nasal mucus and runny nose) spray over-the-counter saline nasal spray (or drops) into each nostril morning and night and with each feeding. After this, suck out each nostril with a bulb suction. Spraying in the saline spray will help clear the nasal mucous and loosen it up so that it can be better suctioned. Your child may gag or cough after the saline is sprayed in the nostrils, this is not unexpected. Keeping your child’s nasal passage open will help them breathe easier and make it easier for them to eat and drink.

 

Disclaimer: This is only an example of phrasing for discharge instructions. It is not meant as medical advice. Please see site disclaimer for further details.

Direct download: Nasal_suction_ercast.output.mp3
Category:general -- posted at: 2:58pm MST

There's a journal club in my living room every few months (or at least there will be - this was the first). Raconteur Adam Rowh, MD joins the show to talk the med lit we dissected by the fireside.
Stuff in this show

  • Prandoni, Paolo, et al. "Prevalence of pulmonary embolism among patients hospitalized for syncope." New England Journal of Medicine 375.16 (2016): 1524-1531. Link
  • Righini, Marc, et al. "Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study." Jama 311.11 (2014): 1117-1124. Link
  • Wang, Ralph C., et al. "Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis." Annals of Emergency Medicine (2016). Link
  • Sakles, John C., et al. "First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department." Academic Emergency Medicine 23.6 (2016): 703-710. Link
  • The Bell Tolls for Renal Colic CT Link
Direct download: Articles_you_need_to_know_-_winter_edition.mp3
Category:podcasts -- posted at: 10:36pm MST

It's time for a mumps outbreak! Here is a basic primer on the very basic basics.

How do you get mumps? 

  • Respiratory secretions, that guy sitting next to you on the airplane with the huge parotid gland and just sneeze in your eye. Not good.

Incubation period

  • How long does this need to cook before mumps is ready for full star spangled disease manifestation? Somewhere between 2-3 weeks.

Presentation

  • The classic presentation is a swollen parotid gland. Usually it’s both, but in a quarter of patients, it’s unilateral parotitis, which can make things tricky when you’re wondering if this patient has acute bacterial parotitis, or mumps. The other salivary glands can swell as well, but much less commonly than the parotid. 
  • All this salivary swelling business may be preceded by a few days of viral syndrome fever , headache, body aches, feeling crappy.  Patients feel bad for a few days, the parotids swell, stay swollen for anywhere from 2  to 10 days. There may, however, be no parotid swelling as well, just a viral syndrome and nothing else (there may also be no symptoms). 

The other issues with mumps

Orchitis. Can be one testicle, can be  both testicles. Females can also have reproductive organ involvements- less than 1% with oophoritis and a similar rate for mastitis. Non reprotrducgei or salivary gland involvement include aseptic meningitis and pancreatitis.

But wait, I can’t get mumps, I’ve been vaccinated. 

  • Unfortunately that’s not 100% protective and sadly, immunity can wane. 

Treatment

  • There is no specific treatment, just supportive care.

Your job 

  • Your job now is to keep it from spreading. In the hospital, droplet precautions. Mumps is most infectious from 2 days before the parotid swelling to at least 5 days after. Hard to quarantine when there's no parotid swelling, but once it starts, 5 days of no school, no work, and separated from family members (not always possible).

Testing

  • We’re getting these recommendations from the health department to collect samples from almost every body fluid, but isn’t blood enough? It turns out that it is not. Serum IGM, which you’d expect to see in an acute infection, may be falsely negative, especially in someone who has been vaccinated. Many different tissues are infected in mumps, so to really figure out if it’s mumps or not, we’ve been advised to get serum, urine, and buccal swabs. By the time the results come back, your patient will probably be finished with quarantine, but from a public health angle, you’re a hero.

Testing advanced level 

  • In unvaccinated patients, IgM is present by day 5 post onset of symptoms. In a vaccinated person, there might not be any IgM and it could have a very quick spike and disappearance. When you get that IgM mumps test back negative 3 weeks after you’ve seen the patient,  just know that that doesn’t mean they don’t or didn't have mumps. 
  • Why buccal swabs? This tests for the mumps virus itself and is very good in the early stage of infection, especially in someone who has had vaccination, which is hopefully everybody, but it’s not. 
  • Why urine testing? Not as sensitive as buccal testing in early infection but currently recommended in our region. I’m guessing to cast as wide a net as possible. 

Call the health department

  • Initiate patient tracking, contact tracking, and have a public health expert take over with following up on test results etc. 

Bottom Line

  • If you see a patient with parotid swelling and there has been a viral prodrome, or perhaps there’s been a mumps outbreak - think mumps. If you have high suspicion, immediately  initiate droplet precautions, collect samples, call the health department, quarantine (at home) and if possible separate from family for 5 days following onset of parotid swelling. Sometimes that last part is not possible, but have them do their best.

Links

  • Specimen Collection (what to order, exact way to collect it). Link
  • Oregon Public Health Mumps Review (mumps overview). Link
  • Oregon Public Health Mumps Main Page (investigative guidelines, case report form). Link
  • CDC Mumps Pinkbook Review (mumps overview) Link
  • CDC Mumps mainpage Link
  • CDC Current Mumps Outbreaks Link
Direct download: Mumps_ERCast.output.mp3
Category:general -- posted at: 9:38pm MST

What were your practice changers in 2016? For me, it was Reuben Strayer's simple phrase for when to give epinephrine in allergic reaction patients: For A, B, or C,  give E. If there is involvement of airway, breathing ,or circulation, give epi. It seems simple when it's spelled out this way, but there can be a lot of hemming and hawing when deciding to give (or not to give) this drug. The other, less clinical, pearl is something learned from former Google engineer Chade-Meng Tang: pick two random people and think, "I hope that person is happy." That's it, just think it, don't have to do anything else. The results are astounding. Now let's hear what our guest panel has to say about what changed their practices in 2016....

 

Simon Carley @EMManchester

 

Michelle Lin @M_Lin

 

Lauren Westafer @LWestafer

  • Elevates the head of the bed to 30-45 degrees when intubating

 

Jeremy Faust @jeremyfaust

  • Recommends E-Cigs as an option for patients trying to quit smoking

 

Jess Mason @Jessmasonmd

 

Al Sacchetti @Sacchettialfred

  • Use ultrasound to confirm foley catheter placement

 

Adam Rowh

  • PATCH Trial
  • Richard Feynman “So my antagonist said, "Is it impossible that there are flying saucers? Can you prove that it's impossible?" "No", I said, "I can't prove it's impossible. It's just very unlikely". At that he said, "You are very unscientific. If you can't prove it impossible then how can you say that it's unlikely?" But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible.”

 

Anand Swaminathan @EMSwami

  • Azithro is losing potency against Strep Pneumo
  • The EKG findings in PE
  • Pre-charge the defibrillator during CPR
  • Use the pelvic binder properly
  • Use the oxygen wave form to confirm pacemaker capture
  • Shared decision making

 

Scott Weingart @emcrit

  • Be careful with hyponatremic patients
Direct download: Practice_Changers_version_2.output.mp3
Category:general -- posted at: 10:29pm MST

If you are on Twitter, there's a good chance you've seen commentary from our guest today Sassy MD. She is a 4th year medical student and gives an unfiltered commentary on the trials and tribulations of med school, life, deciding what shoes to wear, and even the internal dialogue about her attendings.

 

In this episode

  • using twitter for mentorship
  • interview advice on how to answer "what is your greatest weakness"
  • integrating 'nontraditional' education into early learning
  • the importance of textbooks
  • the side of emergency medicine you don't learn on rotations (it's the clerical duties!)
  • choosing a specialty
Direct download: Sassy_MD.mp3
Category:general -- posted at: 10:07am MST

We’re not trained in conflict resolution, but angry patients are a reality in any practice. Listening and empathy can go a long way in this situation. Dike Drummond, a.k.a. The Happy MD, give a step by step strategy for engaging with upset patients.

Links mentioned in this show

Link to detailed explanation and video description of the Universal Upset Patient Protocol

Link to Primary Care RAP

Interested in subscribing to Primary Care RAP? Use ERCAST20 to get a 20% off subscription if you're new to the program.

 

Show Notes

Pearls

  • There are 6 steps to the conversation with a patient who is upset.  

    • “You look really upset.”

    • “Tell me about it.”

    • “I’m so sorry this is happening to you.”

    • “What would you like me to do to help you?”

    • “Here’s what I’d like us to do next.”

    • “Thank you for sharing your feelings with me.”

 

  • An encounter with an angry patient is stressful to the overwhelming majority of providers.  It can ruin your day (or days) and that of everyone else in the office.  Medical training does not prepare students to handle these situations.

 

  • The upset patient protocol is a way of structuring a conversation with an upset patient.  It is a doctor-patient communication tool which encourages the patient to share and vent his/her feelings.  After listening to the disgruntled patient, the protocol helps the physician wrap it up so that he/she can proceed with the clinical part of the office visit.  This protocol works about 85% of the time with angry patients, regardless of the source of the upset.  The remaining 15% will stay upset despite your best efforts to placate them.

 
  • Step 1:  Notice the patient is upset.  

    • Take a deep breath, get present, and make sure that you are centered when you walk in the room.  If you do not notice that a patient is upset, he/she will get even more angry, assuming that you don’t care or that you’re clueless.

    • Sit down.

    • Show that you recognize the patient is upset by saying, “You seem upset.”

 
  • Step 2:  Invite the patient to talk about it.

    • Give the patient permission to tell you about their frustration by saying, “Tell me about it.  Tell me what happened.”

    • Let the patient speak or vent frustration without interruption.  Refrain from being defensive.

    • Breathe and remember Theodore Roosevelt’s phrase:  “They don’t care how much you know until they know how much you care.”   

 

  • Step 3:  Show empathy for the patient’s situation and apologize.

    • You can be sorry for the way the patient feels or for his/her experience without apologizing for anything that you have done.

    • Say something like,  “Wow.  I’m so sorry that you’re feeling this way.  That sounds so frustrating.  I’m so sorry this is happening to you.”

 

  • Step 4:  Find out what’s their agenda.  

    • Ask the patient, “What would you like me to do to help you?”  

    • Sometimes the patient will say, “I just need you to listen.  I needed to tell somebody.”  Other times the patient will ask for something specific, which may or may not be reasonable.  If unreasonable, the provider needs to set boundaries around the relationship and decide what he/she is willing to do.

 

  • Step 5:  Determine what you’re willing to do to address the patient’s concerns.

    • “Here’s what I’d like us to do next.”

    • If the patient requests something ridiculous (such as “Give me $10,000”), it is important to not laugh, get upset, or roll your eyes.  Respond with, “I can understand how you feel.  I’m not willing to do that.  You know that, right?  Here’s what I am willing to do.”  And then you tell them what you’re willing to do.

    • Emphasize what you’re going to do, and not what you’re not willing to do.  The negotiation should be very quick and, typically, you’re right back on track with their frustration diffused.

    • Usually, if you’ve listened to the patient and shown them how much you care, they’ll make a very reasonable request and something that is potentially within your power.

    • Once physicians inform patients about what they’re willing to do within the boundaries of good medicine, patients can then decide whether they want you to continue to be their doctor.  Never put yourself in a position with an upset patient where you feel you’re in danger.  For instance, never prescribe narcotics that you think are inappropriate.  Let the patient know that they’re perfectly capable of seeking a separate medical opinion from another doctor.

 

  • Step 6:  Thank the patient for sharing his/her feelings and trusting your relationship.

    • “Thank you so much for sharing your feelings with me.  It’s really important that we understand each other completely.”

  • The Universal Upset Patient Protocol does not work on 15% of patients.  Nothing works universally, and some patients will remain angry no matter what you say.

  • Everyone in the clinic or office should be trained in the Universal Upset Patient Protocol.  Oftentimes, a receptionist or nurse can placate the patient so that the physician can focus on the medical issues that brought the patient to the office in the first place.  Ideally, physicians and other staff members should rehearse and practice these conversations, so that they are comfortable using these tools when an upset patient walks in the door.

Direct download: upset_patient_ercast.output.mp3
Category:general -- posted at: 11:53am MST

When you are calling a consultant, whatever the specialty, what are you really doing? You are presenting an argument, making a case for what you think should be done, or making the best case for what you think is going on and seeking the benefit of their expertise. One area where this gets a little short circuited is in the acute stroke consult. The short circuit has its roots in the early days of TPA in stroke literature. When the NINDS study came out, my neurologist friends were beyond belief excited. Finally a therapy for stroke! 

At the same time, there was a counter argument. The legendary emergency physician and skeptic, Jerry Hoffman, said, "This data does not support using thrombolytics in stroke, in fact quite the opposite." Therein began the divide that has only grown since and therein began the stroke treatment narratives within neurology and emergency medicine.  For the most part, neurologists favor TPA and many ED docs do not. We read the same studies, all went to medical school and want the best for our patients. I’m not going to debate the merits and dangers of TPA here. I bring this up because this dichotomy leads to stress at the wrong time.

The decision of whether or not lytics are going to be part of your stroke practice needs to be decided before you see an acute stroke patient. Once you make that consult, you are already on the path of potentially giving lytics and if you are going to do it, you should do it it the most expeditious way possible. Not that you can’t advocate for the patient, because you absolutely should. So when you call the neurologist for a patient with an acute stroke stroke patient, be professional and be economical with the presentation, no BS and no unneeded information.

Elements of a Stroke Consult

  • Age
  • Last normal
  • Onset of symptoms and type of symptoms if witnessed
  • Blood sugar
  • Are they on anticoagulants
  • What is the blood pressure
  • NIH stroke score and specific deficits that gave the patient points
  • Where is the patient is on their path to CT

 

 

Now, the consult. This is not a full chitty chat long form conversation, this is a condensed bolus of vital information. 

  • This is a 70 year old male, last seen normal at 9am. At 10 am, family heard some noise in the living room and found the patient stumbling around, weak on the left side. Paramedic blood sugar was 100, normal. Patient is on aspirin but not anticoagulants. Last blood pressure 200/100. Eam shows an NIH stroke score of 6. All points are given for left sided weakness. There is a partial left  facial palsy, left arm and leg cannot resist gravity. We are now 90 minutes after last seen normal and the patient is being packaged for a stat CT.

Done

There will be questions after this, there always are. You have the benefit of a tremendous amount of information: you’ve met the family , shared the same air as the patient, your consultant is only getting the picture you’re painting. There will be talk of heart rhythm, comorbidities, potential exclusion criteria. etc. But that is the initial call. Short, sweet and to the point. 

 

NIH Stroke score training video

Direct download: Stroke_Consult.output.mp3
Category:general -- posted at: 4:00pm MST

Scott Weingart from EMCRIT guest stars in this episode to discuss his approach to two challenging airway cases. The common theme is ketamine and semi-awake intubation (or at least maintaining breathing while inserting the laryngoscope).

Mentioned in this episode

Rapid sequence awake intubation

Rapid Sequence Awake Intubation by EMCRIT

Use something like the EZ-Atomizer - Jet sprayer to administer lidocaine in rapid sequence awake intubation. About 12cc of 4% lidocaine jetted all around the back of the tongue, throat, direct the tip to the cords and epiglottis

2% or 5% topical lidocaine to the back of the tongue with a tongue depressor. It'll slip down the back of the tongue into all the nooks and crannies

Cords not opening during an awake intubation? Try a small dose of propofol to relax the patient and abduct the cords.

Post intubation sedation. Be generous with analgesia and sedation. Rob prefers fentanyl bolus and drip, propofol bolus and drip. If a fentanyl drip isn't readily available, Scott recommends using hydromorphone 1mg IV and then scheduled hypdromorphone in addition to propofol.

Pocket Bougie

Glidescope titanium

Jess Mason's rapid sequence awake intubation narrative learning segment from EM:RAP

Books Scott and Rob are reading

When Breath Becomes Air

A Strange Relativity. Beautiful video done by Stanford University about When Breath Becomes Air author Pail Kalithini

Sapiens

Surrender New York

The War of Art

The Art of Learning

The Slow Regard of Silent Things

Strategery

Strategery

Direct download: 2_tough_airway_cases.output.mp3
Category:general -- posted at: 2:32pm MST

Intro: Scott Weingart explains why he meditates and how it's like 'kettlebells for the brain'.

Main episode: Chris Hicks is a Canadian emergency physician and trauma team leader. In this episode, he gives simple practices to improve your management of an emergency department shift as well as controlling the resuscitation room in a calm, effective manner.

 

Follow us on twitter

Mentioned in this episode

Direct download: Mastering_the_storm_V4.output.mp3
Category:podcasts -- posted at: 12:29am MST

Does anything work to reverse angioedema? If it's hereditary, then icatibant may do the trick. Otherwise, there's not much out there. Fresh frozen plasma (FFP) has it's place in angioedema lore as something that works, but the evidence in its favor is a series of case reports. Emergency physician and angioedema researcher Gentry Wilkerson gives a State of the Union on the known knowns and known unknowns of this sometimes mysterious disease.

Links mentioned in this show

Register for Essentials of Emergency Medicine

Angioedema algorithms

Cicardi, Marco, et al. "Guidance for diagnosis and treatment of acute angioedema in the emergency department: consensus statement by a panel of Italian experts." Internal and emergency medicine 9.1 (2014): 85-92. Link

Bowen, Tom, et al. "2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema." Allergy, Asthma & Clinical Immunology 6.1 (2010): 1-13. Link

Chiu, Alexander G., et al. "Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management." Annals of Otology, Rhinology & Laryngology 110.9 (2001): 834-840. Link

Hassen, Getaw Worku, et al. "Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema." The Journal of emergency medicine 44.4 (2013): 764-772. Link

Direct download: Angioedema_ercast.mp3
Category:podcasts -- posted at: 9:01pm MST