Tue, 21 February 2017
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.
How often to suction?
Breakfast, lunch, dinner and right before bed.
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.
Mon, 13 February 2017
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.
Wed, 1 February 2017
It's time for a mumps outbreak! Here is a basic primer on the very basic basics.
How do you get mumps?
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.
Testing advanced level
Call the health department
Sun, 1 January 2017
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
Jeremy Faust @jeremyfaust
Jess Mason @Jessmasonmd
Al Sacchetti @Sacchettialfred
Anand Swaminathan @EMSwami
Scott Weingart @emcrit
Sat, 19 November 2016
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
Wed, 28 September 2016
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.
Fri, 23 September 2016
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
Now, the consult. This is not a full chitty chat long form conversation, this is a condensed bolus of vital information.
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
Sat, 3 September 2016
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.
Jess Mason's rapid sequence awake intubation narrative learning segment from EM:RAP
Books Scott and Rob are reading
A Strange Relativity. Beautiful video done by Stanford University about When Breath Becomes Air author Pail Kalithini
Tue, 12 July 2016
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
Sat, 30 April 2016
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
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