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Algorithmic social media is stealing your joy and may be making your life dramatically worse. If you haven't watched The Social Dilemma, you probably should sit down and give it a view, especially if you have kids.

Advertising + Algorithm

Misalignment of incentives

Business model in which incentive is to find customers ready to pay to modify someone else's behavior

 

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The Algorithm

Get you to the app and keep you there

Movie Social Dilemma gets it Wrong

Negative trumps positive

Dopamine hit

Addictive, but mostly shallow or perhaps b/c of shallowness

Tribalism & Mob Behavior

Magnification of Fringe Views

Makes assholes more assholey

Attention is the reward on social media, and assholery gets the most attention

Loss of Objective Reality

 

Individual Apps

Facebook

The Worst!!!

A bunch of you are there so EMCrit has to announce new episodes there

Instagram

Just as evil

Reddit

 

Twitter

Sponsored Tweets

Built to inflict misery and turn people into assholes

Reub--bring it to Reddit

Twitter happiness feed

Youtube

Turn off "Up Next"

TikTok

Insanely addictive

Netflix

Algorithm with the right incentives

The News

Algorithm

If you can't change it, don't regard it as important

Google

not just creating an echo chamber

but actually sculpting Truth based on a political agenda

* Switching over to Hey Email

* DuckDuckGo

RSS

The way to have social media goodness come to you

Turn off Notifications

for any social media and for anything else possible

Go Deep instead of Shallow

 

If you have kids, avoid social media until ~16

Jonathan Haidt

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More Stuff to Check Out

* How to go from being an Ass-hole to an AYS-hole on Twitter

* 7 Ways to be Insufferable on Facebook

* How to Use RSS and Itunes to Maximize FOAM Podcasts

* The Online Hierarchy of Needs - Social Media and FOAM

Please ReRead 1984

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Now on to the Podcast...

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So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation.

Upsides of Dexmedetomine (Precedex)

* No respiratory depression

* Opioid sparing/analgesic effect

* Preserves Sleep Architecture

* Sympatholysis

* May be delirium-protective

* May be more hemodynamically stable than propofol

* Good for neurocritical care

Downsides of Dexmedetomidine

* Bradycardia

* Hypotension (especially when the pt is volume depleted)

* Cost (much less of an issue now that it is generic)

* Diuretic effect

* Slow onset

* Constipation

Useful for...

* Post-intubation sedation

* NIPPV sedation

* Procedural sedation

* Add-on to propofol

Other Stuff on EMCrit

* Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)

* PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?

* Dexmedetomidine to facilitate noninvasive ventilation

 

Studies

The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 - Volume 47 - Issue 2 - p e89–e95)

https://www.ncbi.nlm.nih.gov/pubmed/21812509

https://www.ncbi.nlm.nih.gov/pubmed/27035758

Now on to the Podcast...

Labors of Trauma (Blunt Ed.)

So a few weeks ago, I podcasted the Labors of Trauma, a comprehensive list of the responsibilities of a Trauma Team Leader.

EMCrit 278 - Labors of Trauma - Blunt Edition

I promised that I was going to do a part II with my co-conspirator, Chris Hicks.

Hick's Pre-Brief and Leave the Room Checklist

 

St. Mike's New Trauma Bays

Calcium

Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439

New Hemostatic Resus Ratios

* Should we add calcium and fibrinogen to our ratios

New Name for the Pelvic Binder

* We should be calling these Trochanteric Binders

Now on to the Podcast...

 

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Why Can't Emergency Medicine and Trauma Surgery Just Get Along? This is a question we often ask in the USA given our unique Trauma system. It seems custom built to create conflict in the trauma bay. To explore this issue, I got to talk with Joe DuBose and Bill Teeter. This discussion originally was recorded for Joe's new podcast on Trauma Surgery, Tiger Country. Tiger Country has a bunch of episodes that are worth a listen for ED and ICU folks as well.

Joe DuBose

Trauma and Vascular Surgeon at the Shock Trauma Center. Professor of Surgery. Research leader on all things REBOA.

William Teeter

Started as a surgery resident, switched over to EM residency and then Crit Care Fellowship. Now an EM Intensivist down South.

More from DuBose

* Podcast 170 - the ER REBOA Catheter with Joe DuBose

Now on to the Podcast...

I did an initial EMCrit episode on Angiotensin II when the Athos 3 trial was fist published. Today, now that the drug has been available for a while, I wanted to hear from someone smart, with no financial conflicts of interest, on when to actually use this medication.

Rinaldo Bellomo MD PhD

Dr. Bellomo's Bio is too extensive to place here, please check out his Monash Page. Suffice it to say that he is a total badass as a clinical intensivist and a critical care researcher.

 

Renin Angiotensin Aldosterone System (RAAS)

Who Should Get Angio II

* Renin > 175 (or round up to 200)

* Septic Pts on RRT or about to need it

* Patients on pre-illness ACE-I

Rinaldo's Paper in AJRCCM

* Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock

More on this Topic

* PulmCrit- Angiotensin II: five cautions & three comparisons

* Review Article from EMJ

Now on to the Podcast...

Ultrasound signs of pericardial tamponade with my buddy, Jacob Avila. This episode is simulacasted with Core Ultrasound.

Right Atrial Collapse

greater than 1/3 of the cycle is probably the most specific

 

Right Ventricular Collapse

If the RV is collapsing when the mitral valve is open, then that is specific for tamponade

 

IVC

Lead pipe is specific, flat doesn't rule it out (if pt is volume depleted, etc.)

 

Check Out my Prior Episode with Jacob

* EMCrit 256 - RUSH Redux with Jacob Avila

Steve Alerhand has written a great review article in AJEM

Alerhand-Is it Tamponade?

 

Now on to the Wee...

A brief summary of this episode

I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.

Our guest today is Reub Strayer

(@emupdates). He is the author of EMUpdates.com. His research and clinical interests include checklists and standardization, airway, legislative work on the treatment of opioid dependence, and an approach to opioid misuse in the ED.

 

Reub breaks agitated patients down in to 3 groups:

1. Agitated, but Cooperative

Not a problem in the ED. Oral medications or non-pharm techniques.

2. Disruptive without Danger

Use standard anti-psychotics and sedatives, with the understanding that Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation. There are better choices for this group:

* Droperidol monotherapy 5-10 mg IM or 5 mg IV

* Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe

* Olanzapine 10 mg IM (Needs Resp Monitoring)

* Olanzapine 5 mg + Midazolam 2 mg IM or IV  (Needs Resp Monitoring)

* Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)

If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group.

3. Disruptive and Dangerous

* dangerous to staff, dangerous to self

* danger is relative to the resources of the location

Danger could be due to

* The agitation itself or

* An underlying condition that the agitation is preventing from being treated (and may be the cause of the agitation, e.g. tension pneumothorax)

Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test.

Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation)

Intramuscular Medication Administration

* Can go through clothes if you need to [Fleming et al.]

* Reub states maximum volume of up to 20 mls per injection

* Harrington 2005 Administer Single Site 30mL Injection Fosphenytoin - Medsurg Nursing

* Hopkins 2013 Large Volume IM Injections Review of Best Practices (Oncology) - Onc Nurse Advisor

* Ramsay 1997 IM Fosphenytoin Loading High Volumes - Epilepsy Research

Ketamine Brain Continuum

After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited--the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well.

Blue=cognitive tasks for the TTL

Red=TTL must assign to a subteam (operational)

Solid=always happens in every trauma

Dotted=May happen based on patient injuries or severity

 

* Zero Point Survey

* Team Leadership with Cliff Reid

* EMCrit #230 - Resuscitation Communication

* COMM CHECK: More On Resuscitation Communication

 

 

 

 

* Rapid Infusion Catheter

 

Revised Assessment of Bleeding and Transfusion (RABT)

* Penetrating Trauma

* Shock Index > 1.0

* Pelvic Fracture

* Positive Abdominal FAST

>=2 had sensitivity of 84% and a specificity of 77%

World J Surg 2018;42:3560

5 Sites of Bleeding

* Chest

* Intra-Peritoneal

* Retro-Peritoneal/Pelvis

* Thigh

* Street

 

* Hemostatic Resuscitation by Richard Dutton, MD

* EMCrit Podcast 30 Hemorrhagic Shock Resuscitation

 

 

 

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Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology.

Martin Tobin

* Praise for Dr. Tobin

* Bio Page

 

Caution about Early Intubation in COVID-19

p-SILI

From 2 studies, 1 on sheep breathing with a human-equivalent Vt of 502 ml

2nd study was observational with a questionable connection to Vt--it was confounded by a number of other factors

Absence of Obtundation

 

L vs. H Subtypes

 

Physio Diversion - Looking for the Patient that needs more Inspiratory Flow

* Tobin Vent Review in NEJM

 

Basing Respiratory Management of COVID-19 on Physiological Principles

Tachypnea in Isolation is Not an Indication for Intubation

Not indicative of increased WOB

Avoiding Intubation with NIPPV

Correlation of saturation with a host of other evils, but it is possible that the saturation is merely a marker--similar to pH. Vicious cycle of shunt, low SvO2, encephalopathy, decreased resp. drive. COVID has been different, with decreased saturation without the horrible lung injury that normally accompanies it. We are also used to patient discomfort from the disease causing the hypoxemia. Retained good compliance. We have not seen the isolated hypoxemia of COVID in many situations before.

 

The Baffling Case of Silent Hypoxemia

Happy Hypoxemia vs. Silent Hypoxemia

Dr. Tobin defines silent hypoxemia as PaO2 < 60 mmHg with a PaCO2 >39 mmHg (as a PaCO2 < =39) blunts the dyspneic response to hypoxemia

Why don't they have dyspnea vs. why do they have such severe hypoxemia unaccompanied by the degree of standard badness that normally accompanies it

They do not crump

They don't develop multi-organ

Dyspnea

Purely subjective

Advanced age and diabetes may blunt dypsnea

Increase in 10 of PaCO2 causes extreme air hunger

Increase Ve when PaO2 <60, but severe hypoxemia elicits increase in ventilation only when PaCO2 > 39 mmHg [32539537]

Definition of Hypoxemia

Do we need to factor in FiO2? Dr. Tobin and I say no!

I define by pulse ox or (PaO2), doesn't matter how much O2. e.g. "He is still hypoxemic despite being placed on NRB."

When does Hypoxemia Become Dangerous?

 

Pulse Ox Inaccuracy

 

OxyHemoglobin Dissociation Curve Shifts

Fever shifts to the right, Decreased CO2 shifts left

Mechanism of Silent Hypoxemia

ACE2 is expressed in the carotid body and may be partially to blame

COVID breaks our Heuristics

Heuristic representation of how bad their lung disease actually is. Projecting expected course...

COVID first disease that unlinks it

Now on to the Podcast...