EMRA*Cast

In part 2 of her interview with Dr. Haney Mallemat, Dr. Jessie Werner finds out how to manage the ventilator in the ED and reviews some real-life cases with Haney!

As Emergency Medicine physicians we’re tasked with taking care of the sickest of the sick, often before we even have a diagnosis to clarify the clinical picture. Stabilizing critically ill patients may require placing a definitive airway and providing hemodynamic support with pressors. When faced with these challenging situations, what do you do? So you decide to intubate. Now what? What are the different ventilator modes and how do we choose? What does it mean when the vent is alarming? Find out how to select vent settings and troubleshoot problems in Part 2 on becoming a critical care beast in the ED!

• There’s no difference between pressure and volume control
  • If you’re giving a certain pressure, you monitor the volume, and vice-versa
• Remember 6-8cc/kg of volume (using ideal body weight) for lung protective strategy
• Peak pressure is the sum of resistance and compliance
• Plateau pressure measures compliance
• High peak pressure indicates a resistance problem
• High peak AND plateau pressure indicate the lungs are stiff
• To diagnose a ventilator problem think DOPES:
  • D: displaced tube or cuff problem
  • O: obstructed tube
  • P: pneumothorax
  • E: equipment problem
  • S: breath stacking
• To fix a ventilator problem think DOTTS:
  • D: disconnect from the ventilator and allow for full exhalation
  • O: oxygenation - are they bagging okay?
  • T: tube in the right place
  • T: tweak the vent to prevent breath stacking
  • S: ultraSound  

• Weingart, Scott D. "Managing initial mechanical ventilation in the emergency department." Annals of emergency medicine68.5 (2016): 614-617.

EMRA*Cast host Dr. Shreyans Sanghvi takes a deep dive on the history, current practice, and future direction of cardiac arrest management and advanced resuscitation medicine with research pioneers Dr. Lance Becker and Dr. Sam Parnia.

OverviewEach year hundreds of thousands of Americans suffer from cardiac arrest out of the hospital. CPR has been a core tenet in the rescue algorithm for patients in cardiac arrest, but how do we transform this age-old treatment with today's advances in technology, and to where do we turn when CPR alone is ineffective?

Dr. Lance Becker, chair of Emergency Medicine at Northwell Health North Shore - LIJ, and Dr. Sam Parnia, director of Critical Care Research at NYU Langone Medical Center, discuss lessons they've learned along the way dedicating their lives to the research and treatment of patients in cardiac arrest.  

Key Points

1. CPR is the single most-effective measure in the resuscitation of patients in cardiac arrest.
2. CPR when used in tandem with real-time biomarkers such as end tidal CO₂, arterial line pressure, and ultrasound can be utilized to monitor CPR efficacy in real time.
3. A team-focused, multi-disciplinary video review of cardiac arrest management can help improve outcomes in patients and identify barriers to achieving adequate reperfusion.
4. Upon achieving ROSC, provider efforts should be dedicated to minimizing the amount of reperfusion injury patients incur.
5. Providers should resist the urge to correct acidosis (in the immediate post-ROSC phase) by increasing the ventilator respiratory rate, as decreased CO₂ levels can precipitate cerebral vasoconstriction and worsen brain ischemia.

Dr. Jeremy Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada and ARVD.

Lumps and Bumps: Can't-Miss Diagnoses in Syncope 

Host: Alex Kaminsky

Guest: Jeremy Berberian, MD

• Associate Director of Resident Education, ChristianaCare
• Editor-in-chief: EMRA EKG Guide, EMRA Ortho Guide, and the upcoming Emergency ECGs: Case-Based Review and Interpretations, with Amal Mattu and William Brady
• Faculty editor: EM Resident Monthly ECG Challenge
• Creator: ECG Greeting Cards©, a collaboration with MPP and JerBer Productions

EPISODE OVERVIEWResidents are well-programmed to recognize cardiovascular emergencies such as STEMIs at a glance. However, during a busy shift it can be easy to overlook dysrhythmias and other electrophysiologic urgencies and emergencies. Syncope is a prime example of a chief complaint that may be uncovered with an EKG alone -- however, syncopal emergencies are often subtle and nuanced. Dr. Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada, ARVD and more.

KEY POINTS

Wolff-Parkinson-White (WPW)

Prevalence: 0.7 to 1.7 per 10000

OverviewAccessory Pathway Connecting the atria to the ventricle. In some instances, this can cause the accessory pathway to travel FASTER than through the AV node.

• Orthodromic (Narrow): Travels down the AV node (can bypass)
• Antidromic (Wide): Bypasses AV node and UP the his-purkinje system.

Courtesy of CardioNetworks: Free use image

Key Features:

 Image: Courtesy of EMRA EKG Guide

• Short PR (less than 120ms)
• “Delta” wave -- which is a “slurring” of the QRS complex
• QRS might be “a little” wide (still 2mm with a negatively deflected T in right precordial leads (V1-V3)
• Potentially diagnostic as isolated EKG finding.

Type 2:

• ST elevation in right precordial leads (V1-V3) with a “saddleback.” Within the STE.

• Not completely diagnostic but concerning fr workup.

Clinical Criteria (EKG Findings PLUS one or more):

• SYNCOPE
• Nocturnal Agonal Respirations
• • Brugada gets WORSE with parasympathetic stimuli.
• Family member with known Type 1
• Observed/Documented VT/VF
• Sudden cardiac death in family member

OverviewDo you ever get overwhelmed with all the ED analgesic options? In part 2 on ED Pain Management, Dr. Sergey Motov helps break things down, reviewing a few cases and finishing with Sergey’s 10 Commandments of ED Pain Management.

Key PointsSergey's 10 Commandments of ED Pain Management

1. Titrate opioids regardless of initial dosing regimen: weight-based, fixed, or nurse-initiated.
2. Use alternatives (to IV) routes of analgesic administration: PO, PR, IN, SubQ, nebulized, topical.
3. Utilize sub-dissociative dose ketamine for selected acute and chronic painful conditions.
4. Educate patients about appropriate expectations of pain course and management.
5. Embrace a concept of channels/enzymes/receptors targeted analgesia.
6. Use NSAIDs based on their analgesic ceiling dose.
7. Attempt to use non-opioid analgesics whenever possible.
8. Promote nerve blocks for a variety of acute painful conditions (trauma, infection, inflammation).
9. DO NOT prescribe long-acting opioids, SR/ER opioids, or fentanyl patches in the ED or at discharge.
10. If indicated, DO prescribe a short course of immediate release opioids (preferably morphine sulfate IR) at discharge and arrange proper follow-up.

Resources and References

1. Cisewski DH, Motov SM. EMRA Pain Management Guide. EMRA. Dallas, Texas:2020. • App version available within MobilEM at iTunes and Google Play.

1. Motov SM. PainFreeED.com.

In part 1 of her interview with Dr. Haney Mallemat, Dr. Jessie Werner discusses using pressors in the ED. Stay tuned for part 2 on managing the ventilator!

As Emergency Medicine physicians we’re tasked with taking care of the sickest of the sick, often before we even have a diagnosis to clarify the clinical picture. Stabilizing critically ill patients may require placing a definitive airway and providing hemodynamic support with pressors. When faced with these challenging situations, how do you choose the right pressor? What’s the dose? When do you add another agent? What about fluids? We answer all these questions and more in this episode of EMRA CAST. Also, stay tuned for the follow-up to this episode which covers vent management in ED.  We’ve got you covered with all the tips you need to become a critical care beast in the ED!

• The RUSH protocol (which includes the HI-MAP technique Dr. Mallemat mentions) – Rapid Ultrasound for Shock and Hypotension.

• Perfusion is composed of the tank (preload), the pump (cardiac output), and the pipes (systemic vascular resistance).  Hypotension or shock can be caused by ANY of these, so consider performing ultrasound using the HIMAP protocol: HEART, IVC, MORISON’S POUCH, AORTA, and PULMONARY to determine the cause of the hypotension and tailor your resuscitation.
• Pressor Algorithm:
  • As long as there is not evidence of a decreased EF or another cause of hypotension, Haney recommends starting with fluids to resuscitate a hypotensive patient.
  • If a patient is critically ill and/or not responsive to fluids, consider starting norepinephrine. It’s okay to start it peripherally!
  • If the patient is profoundly vasoplegic and norepinephrine is not working, consider adding vasopressin at a dose of 0.03 mg/kg.
  • After that point, you can consider starting epinephrine at a higher dose, or greater than 0.05 mcg/kg/min to get the most vasopressive effect. There is no known maximum dosing, but organ ischemia - particularly gut ischemia - can occur.  
  • Dopamine has fallen out of favor due to concern over arrhythmogenic properties; however, you could consider using dopamine if a patient is bradycardic AND hypotensive (for example, if they’re beta-blocked). If a patient has a “pump” problem with a significantly reduced EF, you should consider dobutamine in conjunction with cardiology or an intensive care specialist.

• Rezaie S. RUSH protocol: Rapid Ultrasound for Shock and Hypotension. ALiEM Website. https://www.aliem.com/2013/06/rush-protocol-rapid-ultrasound-shock-hypotension/. Updated 6/1/2013. Accessed 12/13/2018.

Alpert Medical at Brown University PGY3 @JessWernerMDEMRA Cast Episodes

Associate Professor of Emergency Medicine at Cooper Medical School Triple boarded in EM, IM, CritCare Medicine.  Internationally recognized educator in CC Medicine. Hospital Affiliation: Cooper Medical School @CriticalCareNowEMResident Articles

Host:   Alex Kaminsky, MD PGY-3 UCSF-Fresno (@Alex_KamskyEM)

Guest: Stephanie Benjamin, MD (@StephBenjaminMD)EMS/Disaster Fellow, UC-DavisAuthor: “Love, Sanity, or Medical School”- https://www.thirdyear.org/

Overview: 

In this episode Dr. Kaminsky sits down with veteran journal writer, award winning author, lecturer and current EMS/disaster fellow Dr. Stephanie Benjamin to discuss tangible ways to combat burnout: beyond the buzzwords and by actively building resiliency via personal or medical journaling. Dr. Benjamin discusses the strong medical origins to journaling, her own path and experiences into writing, the evidence-based physical and mental benefits of writing and how residents can delve into combating burn-out in a meaningful and realistic way. What we do is HARD. What we see is difficult. We need outlets to cognitively offload and unpack. Journaling is one way to actively (or passively) practice mindfulness outside of meditation and yoga.

Key Points:

•  Journaling has deep roots in medicine. From Queen Victoria’s personal physician, to modern day
• Medical culture and education have deep roots in separating emotion from patient interactions and experiences. Journaling and having meaningful and purposeful reflection go against the way we are trained, even today.

How to Journal:

Step 1: There are no rules. This is for YOU, not public consumption

Step 2: Be HONEST with yourself. This is a time for reflection and cognitive off-loading. You’re human. Recognize your own success, experience and shortcomings.

Step 3: Avoid the existential questions at first. Start small, work your way up.

Step 4: Writer’s Block? Find a prompt. Answer a pointed question. Doodle. It doesn’t matter.

Remember, just a couple times per month is enough to reap the physical and psychologic benefits of journaling. Do it!

References and Works:  

• https://www.acep.org/who-we-are/50Years/WhatsYourMoment/first-place-stephanie-b-benjamin-md5/
• Baikie K. A., Geerligs L., Wilhelm K. Expressive writing and positive writing for participants with mood disorders: An online randomized controlled trial. J Affect Disord. 2012; 136: 310–319. 10.1016/j.jad.2011.11.032

Baker JR, Moore SM. An opportunistic validation of studies on the psychosocial benefits of blogging. 2011; 10.1089/cyber.2010.0202. Epub 2010 Nov 3. PMID:21117978

Do you ever get overwhelmed with all the ED analgesic options? Dr. Sergey Motov from Maimonides Medical Center in Brooklyn helps breaks down ED pain management. We cover everything from topical NSAIDs to ketamine infusions. Curious which opioid to go with or what dosing? Look no further.

Key Points:

1. Remember to set appropriate pain management expectations. The goal is to make the pain tolerable, not to eliminate it. The more you include your patient in your decision making, the more in control they will feel.
2. NSAIDs are a go-to first option. If a patient doesn’t respond to one class, try another. And don’t forget about topical NSAIDs like diclofenac! Reasons to avoid this class would be history of GI bleed or CAD.
3. Ketamine is a great option for acute pain. 0.3mg/kg in a bolus over 30 minutes followed by 0.1mg/kg/hr during their ED stay. Use these slow infusions to avoid dysphoric reactions. Don’t be afraid to use ketamine in combination with other analgesics for optimal pain management.
4. Neuropathic pain is difficult to manage. Options include antidepressants, lidocaine infusion, gabapentin.
5. Nerve blocks are amazing. From a greater occipital nerve block for migraine to serratus anterior block for rib fractures. There are so many more applications. “If there is a nerve, it can be blocked.” Shout out to my favorite: a hematoma block!
6. Opioids are dangerous but they have a definite role in acute pain management. Morphine is less associated with euphoria and is a good start if choosing to treat with opioids. Oxycodone and hydromorphone are weaker alternatives and have a higher risk of substance abuse; avoid them if possible.

Resources and References:

• https://www.emra.org/books/pain-management/painmgtguide/
• http://www.painfree-ed.com/

Do you ever feel like a fake, a fraud? Imposter syndrome can make you feel a pervasive sense of intellectual fraudulence, despite all the evidence to the contrary. In this episode, Dr. Kim Bambach discusses imposter syndrome with Dr. Jamie Hope including strategies that you can use to combat it. Host:Kim Bambach, MD Ohio State University, PGY3 @kimbambachhttps://twitter.com/kimbambach Guest: Jaime Hope, MD Assistant Professor Beaumont Hospital, Royal Oak @DrHopeHealth

Key Points:

1. Watch out for the typical signs and symptoms: These include devaluing your accomplishments, attributing your accomplishments to external causes, constantly comparing yourself to others, and a negative inner “bully” monologue. 
2. Go first: Be the first to speak up about imposter syndrome, because acknowledging those feelings gives others a chance to feel understood and helps you recognize that you are not alone. 
3. Put your name in the hat: Don’t let imposter syndrome hold you back when it comes to professional development. Apply for that award, leadership position, or job even if you don’t feel 100% qualified. Imposter syndrome can cloud your ability to see your own value and strengths. 
4. Lift as you climb: When you recognize imposter syndrome in others, use your voice and your social capital to advocate for them.  Focusing outward on lifting up others can help you combat imposter syndrome. You can do this at any stage of training.
5. Does it pass the “why” and “who cares” tests?: When you are thinking of all the things you “should” be doing, ask yourself if you can articulate a good reason why you should take on that project and the larger impact of why it is important to YOU. There is no single path to success.
6. Change the channel: When you notice that your inner bully podcast is playing on full blast, change the channel to a different topic. Ask yourself- would you say those things to a friend? 

Resources and References:

https://feminem.org/2018/01/30/overcoming-imposter-syndrome-dont-fake-youve-made/

https://feminem.org/2018/06/07/imposter-syndrome-part-2/

In this episode, Dr. Tiffany Proffitt talks with Dr. Esther Choo about tangible ways to view and address gender disparities in emergency medicine.

Recorded at ACEP 2018 on the Expo floor. A discussion with Dr. Esther Choo on overcoming gender disparities in medicine as well as advice to residents and core faculty for implementation of techniques to encourage change and advancement. Introduction to Dr. Choo’s new start up Equity Quotient.

Dr. Choo’s Top 3 for Overcoming Gender Disparities in Medicine:

1. Find your support network - there are local and national groups!
2. You are NOT alone!
3. Continue to work to improve the problem as you move up.

Just a Few Support Networks:

• Your own hospital’s women’s group – if it doesn’t exist, reach out to your faculty and start one!
• EMRA
• Academy for Women in Academic Emergency Medicine 
• American Association of Women Emergency Physicians
• FemInEM: 
• Dr. Choo

Citations for Any Relevant Articles

• Anna S. Mueller, Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O'Connor, and Vineet M. Arora. Gender Differences in Attending Physicians' Feedback to Residents: A Qualitative Analysis. Journal of Graduate Medical Education: October 2017; 9(5): 577-585.
• Dayal A, O’Connor DM, Qadri U, Arora VM. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training. JAMA Intern Med. 2017;177(5):651–657.

Lakeland Health PGY3 @ProMammaDocEMRA CAST EpisodesEMResident Articles

Associate Professor of Emergency Medicine at the Oregon Health & Science University (OHSU) Former president of AWAEM FemInEM Advisory Board member Co-founder of Equity Quotient  @choo_ek

Overview:

With an upcoming election, social unrest and a global pandemic - there’s a lot to get fired up about.  But what’s our role as residents? PGY2 Kate Joyce talks with Dr. Marina Del Rios, Dr. Dara Kass and Dr. Alister Martin about a program that registers patients to vote in the ED, social emergency medicine, policy and advocacy.  We’ll round things out by talking about how to get involved - without putting your career in jeopardy.

Key Points:

Social Emergency Medicine recognizes the importance of addressing the social determinants of health in the Emergency Department through direct practice, community engagement, advocacy and research.

Many of our patients have not been introduced to the political process.  For others, it may not be safe for them to go to the polls.  VotER is a nonpartisan project that allows patients to register to vote or request absentee ballots while they wait, without adding to the work burden of providers.    

Drs Del Rios, Kass and Martin lay out a few examples and suggest ways to get involved in advocacy responsibly as residents.

Without addressing issues like housing, hunger, addiction, poverty and health disparities, we will continue to play “whack a mole” in the ED with problems that we cannot treat medically.  Getting involved in upstream approaches gives providers an avenue to get at these issues.

10 tips for getting fired up without getting fired

• VOTE on November 3 and in EVERY election.

2) Hold elected officials accountable and SHOW UP to local and community events.

3) Find arenas where your position as a resident can add value to the discussion.

4) INVEST in your time as a resident - that’s why we’re here!

5) Be aware that your decisions on HOW you practice advocacy can seriously impact your career.

6) Avoid sharing ANY kind of identifying information about patients.

7) Know your institution’s rules about in-person advocacy, publications, social media, lobbying and especially talking to the press.

8) Don’t feed the trolls! Keep it classy and do your research so you know your stuff.

9) Have conversations with people outside of your silo.

10) Remember that getting involved at a LOCAL level can have the biggest impact.

Resources and References: 

• Register to vote, check your registration status, and find what’s on your ballot https://www.vote411.org/
• American College of Emergency Physicians Section on Emergency Medicine https://www.acep.org/how-we-serve/sections/social-emergency-medicine/
• The Andrew Levitt Center for Social Emergency Medicine https://www.levittcenter.org/
• Download or order your free VotER kit to start providing voter registration information in your hospital https://vot-er.org/
• National Conference of State Legislatures: Find information about same-day voter registration, early voting, or requesting absentee ballots. https://www.ncsl.org/
• Information on fellowships in social EM and population health from the EMRA Fellowship Guide https://www.emra.org/books/fellowship-guide-book/20-population-health-and-social-emergency-medicine/