EMplify by EB Medicine

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Rob Orman, MD, founder of Orman Physician Coaching, about career disillusionment.

• Career Disillusionment: What is it? How do we combat it? Should we combat it? 
• A frog in boiling water... 
• Burnout
• Two questions to ask yourself
• How coaching can help
• The advice trap
• A framework to explore your career and life goals

More at Orman Physician Coaching. 

In this episode, Sam Ashoo, MD interviews Rawad Rayes, MD and Eva Tovar Hirashima, MD, MPH – two of the authors of the August 2022 PEMP article on Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department.

Episode Outline:

How common are pediatric firearm injuries? 

What is the most common location of these injuries? 

Is there much literature published on this topic?

Epidemiology 

• What’s been the trend in pediatric firearm injuries over the past 10 years? 
• Do we have any idea how/why these are occurring (ie, accidental, intentional, etc)

Terminology: For those unfamiliar with firearms (table 1)

Ballistics: Mechanisms of damage. 

Pre-hospital care

• Trauma center transport
• Prehospital hemorrhage control -- Combat application tourniquet, anything else? 

ED Evaluation

• SIPA -- What is it and why use it? 
• Primary survey -- Tachycardia -> delayed cap refill -> hypotension in children? 
• Secondary Survey
• Diagnostic Studies: 
• Damage Control Resuscitation
• Wound Care -- Do we remove projectiles? Can they stay in? 
• Antibiotics 
• Joint Involvement
• Compartment Syndrome -- 3 As vs 6 Ps
• Rhabdomyolysis

Controversies

• CTA for all injuries? 
• Hemostatic devices -- Any role for these in the ED? 

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Andrew Phillips, MD, MEd, founder of EM Coach, about artificial intelligence and emergency medicine education.

EM/Critical care practice - what’s that like? 

EM Coach - what is it? 

Artificial Intelligence -

• What is it and how does EM Coach use it? 
• The algorithm
• How did you create it? 
• What does it do? 
• The evidence behind it

How and where to access EM Coach

In this episode, Sam Ashoo, MD interviews Lela Bachrach, MD, MS, Larissa Truschel, MD, MPH, and Makini Chisolm-Straker, MD, MPH - the authors of the July 2022 PEMP article on Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to human trafficking. 

Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department 

EMplify - Sept 2022

Episode Outline:

Differential Diagnosis

• What is the differential diagnosis for this scenario in the ED?
• Are these diagnoses mutually exclusive ?

EMS/Prehospital Care

• What role do EMS providers play in the recognition of trafficking?

ED Evaluation

• What are common presentations/complaints that may represent trafficking?
• Examination: Privacy, use of a separate room, how do we accomplish this with minors?
• Ground rules: What does this mean? How do you state this in your practice? Do you find this dissuades patients form reporting?
• Technology: What if they are on the phone?
• History - HEADS-ED
• Physical examination - Findings that lead to suspicion, documentation best practices.

Diagnostic Studies

• Imaging: Any role for this?
• Lab testing: STI, anything else?
• Screening tools: Trauma-informed care, PEARR tool
• Local laws differ by state. How do we handle this with patients? Does it dissuade reporting?
• "Rescuing mentality" and what that means in the ED

Treatment 

• Medical
• Beyond medicines: Local services, national hotline

Special Populations

Diagnosis: What to chart? 

National Human Trafficking Hotline 

https://humantraffickinghotline.org/

In this episode of EMplify: Conversation – Sam Ashoo, MD, and TR Eckler, MD, speak with John Roberts, MD, MPH, about his work with the International Medical Corps and his efforts in Ukraine.

Topics include:

• What is the International Medical Corps (IMC) and what does it do?
• What has IMC been doing in the U.S.?
• What is involved in disaster response?
• What has IMC been doing in Ukraine?
• What are the conditions like in Ukraine now?
• How does bombing of civilian areas affect Ukraine and the IMC projects?
• How can we support IMC efforts?
• How can we volunteer with the IMC?
• How does IMC balance long-term efforts and short-term relief to prevent harm to communities?
• How has the war in Ukraine effected surrounding areas?
• What has been most frustrating and most rewarding for you in your work with IMC?
• How did you start your career in disaster medicine and how would someone interested in it follow your footsteps?

Links

IMC Website

IMC Jobs

Roster Positions

Roster position - MD

Roster position - Nurse 

Roster position - Nurse Practitioner 

Roster position - Midwife 

Disaster Medicine

The Nuts & Bolts of Global EM, free e-book

In this episode, Sam Ashoo, MD interviews Adam Sigal, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to valvular emergencies. 

Managing Acute Cardiac Valvular Emergencies in the Emergency Department

EMplify - August 2022

Episode Outline:

Why Valvular disease? 

• How common is it? 
• How often do we see it in the ED? 
• Which valves are we talking about? 

Aortic Valve Disease

• Types and causes

Mitral Valve Disease

• Types and causes

Tricuspid and Pulmonic Disease

Differential Diagnosis

• acute coronary syndromes (ACS)
• pulmonary embolism
• tamponade
• chronic obstructive pulmonary disease (COPD)
• pneumonia
• pneumothorax

Prehospital Care

• Evaluation of chest pain
• History
• Shock 

ED Evaluation

History

• Aortic Stenosis
• Aortic Regurgitation
• Mitral Stenosis
• Mitral Regurgitation

Physical exam findings 

Diagnostic Testing 

• Labs
• ECG
• CXR
• Bedside US
• Formal ECHO

Treatment

Special Populations

• Prosthetic valves
• Pregnant patients

See Episode Page

In this episode of EMplify, Sam Ashoo, MD reviews recent updates on the following topics:

COVID-19

• Public health emergency extended
• Cases increasing
• Medications and Vaccinations available
• Pharmacists prescribing COVID medications
• CDC COVID Therapeutics website
• HHS COVID Therapeutics Locator

Monkeypox

• Cases increasing
• Vaccination
• Testing
• FOAMED post on Diagnosis and Treatment
• PPE
• Science Direct article on Monkeypox 3I Tool

Medication Shortages

• Benzodiazepines
• FOAMED post on benzodiazepine equivalence
• American Society of Health System Pharmacists (ASHP)

988 Crisis Line

Baby Formula Shortage

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss meningococcal meningitis and the recent outbreak in Florida.

Topics discussed include:

• Which vaccines are currently approved by the FDA and recommended by the CDC.
• The difference between the MEN ACWY vaccine and the meningococcal B vaccine.
• What the current recommendations are for those exposed.
• Challenges for healthcare providers treating patients who have been exposed or have symptoms.

Further reading:

Hogan AN, Brockman II CR, Santa Maria A. Emergency department management of adults with infectious meningitis and encephalitis. Emerg Med Pract. 2022 Apr;24(4):1-24. Epub 2022 Apr 2. PMID: 35315604.

CDC Meningococcal Disease and Vaccination.

As always, we value your feedback. Please take our listener survey.

See the episode page for more details.

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss high sensitivity troponin testing and clinical pathways.

Topics discussed include: 

• Which troponin assay are you currently using and what are its limits of detection? 
• Do delta troponin results only count if they increase? 
• If the test result is indeterminate, then what? repeat in 1 hr (European standard), repeat in 3 hours (depending on chest pain onset), or just admit if the HEAR(T) score is high? 
• What does one negative troponin on presentation mean? No death in 30 days to 1 year but still missed MI?
• And more... 

• Anand A, et al; HiSTORIC Investigators†. High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial. Circulation. 2021 Jun 8;143(23):2214-2224. doi: 10.1161/CIRCULATIONAHA.120.052380. Epub 2021 Mar 23. PMID: 33752439; PMCID: PMC8177493.
• Chapman AR, et al. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017 Nov 21;318(19):1913-1924. doi: 10.1001/jama.2017.17488. Erratum in: JAMA. 2018 Mar 20;319(11):1168. Soerensen NA [corrected to Sorensen NA]. PMID: 29127948; PMCID: PMC5710293.
• Chenevier-Gobeaux C, et al. Multi-centre evaluation of recent troponin assays for the diagnosis of NSTEMI. Pract Lab Med. 2018 Feb 26;11:23-32. doi: 10.1016/j.plabm.2018.02.003. PMID: 30014015; PMCID: PMC6045566.
• Chiang CH, Chiang CH, Lee GH, Qian F, Chen SC, Lee CC. Time to Implement the European Society of Cardiology 0/1-Hour Algorithm. Ann Emerg Med. 2020 Nov;76(5):690-692. doi: 10.1016/j.annemergmed.2020.05.038. PMID: 33097132; PMCID: PMC7575504.
• McCarthy CP, Januzzi JL Jr. Increasingly Sensitive Troponin Assays: Is Perfect the Enemy of Good? J Am Heart Assoc. 2020 Dec;9(23):e019678. doi: 10.1161/JAHA.120.019678. Epub 2020 Nov 26. PMID: 33238785; PMCID: PMC7763764.
• Neumann JT, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377. PMID: 31242362.
• Miller J, Cook B, Singh-Kucukarslan G, Tang A, Danagoulian S, Heath G, Khalifa Z, Levy P, Mahler SA, Mills N, McCord J. RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial. Contemp Clin Trials Commun. 2021 Apr 23;22:100773. doi: 10.1016/j.conctc.2021.100773. PMID: 34013092; PMCID: PMC8114080.

In this episode of EMplify: Conversation, Sam Ashoo, MD and Rob Orman, MD discuss cognitive reframing.

What is cognitive reframing you ask? It is a tool for dealing with a particularly difficult event. In our case, we discuss the “near miss” medical case and how it impacted a physician. Then we discuss how the use of cognitive reframing can help improve our perception of these “near miss” events in medicine. We also discuss what this tool can do for our longevity in medicine, regardless of our career choices. So take a listen. You may be surprised how this tool can be used in all aspects of your life.

Rob Orman refers to a videos he created for a client for the post-shift power-down. You can find it and other helpful videos on his YouTube channel.

Also, if you would like to learn more about Dr Rob Orman’s coaching services, visit his home page .

As always, we value your feedback. Please take our listener survey.

See the episode page for more details.