EMRA*Cast

Host: Miguel Reyes, MD

Guest: Aga De Castro, MD

Overview: We discuss what events led Dr. De Castro to be interested and eventually pursue a simulation fellowship, what it’s like being a sim fellow, what the fellowship looks like, the various kinds of sim fellowships, and different career possibilities you can pursue with the fellowship.

Key Resources:

• https://www.emra.org/fellowships/simulation-fellowships/

• https://www.emra.org/books/fellowship-guide-book/23-simulation/

• https://www.saem.org/simulation

Key Points:

• Sim fellowships are non ACGME accredited - thus follow the pay rate.

• Fellowship length varies, 1 or 2-year tracks 

• Sim fellowship varies quite a bit, look into what kind of sim interests you

Host: Jessie Werner, MD

Guest: Amal Mattu, MD

Overview: In this episode, Dr. Jessie Werner hears Dr. Amal Mattu’s 10 Pearls for Success in Residency. These pearls were developed for Interns but will benefit any level of training. Follow this advice and you’re sure to be a star resident. 

Key Resources: 

Check out Dr. Amal Mattu’s White Board Teaching with his 10 Pearls for Success below:

• https://drive.google.com/open?id=0BzGTqddnb96vVWo1ZWY4a01tazRTTGJKUjExZlRKeUFLVzBV

Key Points:

• Learn the names of the Nurses and Techs! Thank them often. Let’s face it, they spend more time with the patients than we’re able to. They know when something’s not right and they will catch things that will help you. 

• Don’t manage sick patient’s on your own. EM is a team sport. Always notify your senior or attending about a sick patient. They’ll respect your good judgment and trust you more!

• Don’t judge patients or consultants without walking a mile in their shoes. Everyone has their own story. Be empathetic and compassionate - it will make you feel better too.

• Peter Rosen “Nobody woke up this morning and decided to ruin YOUR day.” Happiness is you choice. Be happy, stay positive. Enough said?

• Nobody expects you to know much (yet). But we do expect you to be 100% reliable. Residency is a time of learning! It’s ok to not know things but show up on time (or early), follow through on tasks, and give everything your best effort. 

• Never ever, ever lie. If you don’t know something (or didn’t do something), be honest. This is where your reputation is made. You will gain the trust of your colleagues and attendings by always being honest. We don’t care that you don’t know or forgot to do something. Just admit it and offer to fix it!

• Want to get smart? Do two things: 

• Read up on at least one patient per shift

• Ask lots of questions

Learning in residency can feel overwhelming. A great and manageable way to learn is by taking it one step at a time by reading about one thing you saw after every shift. Take advantage of your attending’s and consultant’s knowledge! Ask why they chose Roc over Succs or keppra over phenytoin… 

• Never be arrogant. You’ll be wrong many times in your career. Learn humility now. Even the best, most seasoned physicians have to look things up. Overconfidence leads to errors. Stay humble.

• Eat and hydrate during every shift. You won’t be able to be the best for your patients if you haven’t taken care of yourself. We promise you won’t lose points for having a snack or going to the bathroom. Eat, drink, pee!

• Never forget what a privilege and responsibility it is that people who don’t know you ask for your help on the worst day of their life. You went into medicine to help people. Hold onto your compassion and empathy. Remember what an honor it is to have people place their trust and confidence in you as an Emergency physician. 

EMRA*Cast Host Dr. Miguel Reyes sits down with Dr. Kevin Baumgartner to discuss Toxicology Fellowships. Listen in as they discuss what events led Dr. Baumgartner to be interested and eventually pursue a toxicology fellowship, what its like being a tox fellow, what the fellowship looks like, and different career possibilities you can pursue with the fellowship.

Key Resources:

• https://www.acmt.net/

• https://www.emra.org/be-involved/committees/toxicology-committee/

• https://www.emra.org/books/fellowship-guide-book/27-toxicology/

Key Points:

• Tox fellowships are ACGME accredited - thus follow the pay rate.

• All are 2-year fellowships 

• If no local tox contacts use the links listed above for job opportunities and guidance

EMRA*Cast host Dr. Alex Kaminsky takes a deep dive on the topic of Acute Respiratory Distress Syndrome (ARDS) with Dr. Sean Hickey and Dr. Evan Leibner. 

Host:

• Alex Kaminsky MD: PGY-3 UCSF Fresno

Guests: 

• Sean Hickey MD: PGY3 Mt. Sinai Hospital, NYC
• Evan Leibner MD: ED/Crit Care Asst. Prof Mt. Sinai Hospital, NYC

Overview:

Broad Strokes: ARDS is diffuse interstitial pulmonary edema secondary to increased pulmonary vasculature permeability. This causes a disruption in gas exchange.

More precise definition: Acute Respiratory Distress Syndrome (ARDS) is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue with hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.

Etiology of injury pattern must be from a non-primary cardiopulmonary source.

Phases of Histologic Patterns:      

Broad Strokes: Histologically in the lungs "diffuse alveolar damage" (DAD)

Initial response to injury: 

Exudative phase, immune cell mediated damage to alveoli.

- Protein rich fluid buildup in the interstitium and alveoli.

- Inflammatory cytokines released leading to recruitment of macrophages/T-cells

-Any injury during this stage is worsened by stretch on alveoli by mechanical ventilation

Second phase is proliferative phase 

- Beginning of healing process.

- Edema begins to be reabsorbed.

- Alveoli gradually regains integrity and function.

Third phase: 

- Fibrotic phase

- Does not occur in all ARDS patients; linked with higher mortality

MOST COMMON CAUSES:

• Sepsis
• Aspiration (Hamman Rich Syndrome)
• Pneumonia
• Trauma
• Massive Transfusion
• TRALI
• Drug Overdose: ASA, Opioids, Cocaine,
• Pancreatitis

Diagnosis:  

The Berlin Criteria

1. Respiratory symptoms within ONE WEEK of clinical insult.
2. Bilateral opacities on imaging – Not fully explained by effusion, lobar/lung collapse, or nodules.
3. Respiratory Failure not fully explained by cardiac failure or volume overload. An objective assessment to rule out hydrostatic pulmonary edema is required. *
4. A moderate to severe impairment of oxygenation is present while on >5 of PEEP

*Either objective assessment (echo) which excludes hydrostatic edema, or risk factors for ARDS (sepsis, pancreatitis, trauma, pneumonia).

Primary Literature:

1. The ARDS Definition Task Force*. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA. 2012;307(23):2526–2533. doi:10.1001/jama.2012.5669
2. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018;319(7):698‐710. doi:10.1001/jama.2017.21907

Evaluation of Oxygenation: The P:F Ratio

• PaO2/FiO2 ratio is the ratio of arterial oxygen partial pressure to fractional inspired oxygen
• At sea level normal is > 500mmHg
• • Mild ARDS: PF 200-300
  • Moderate ARDS: PF 100-200
  • Severe ARDS: PF < 100

Can be used as a rough guide to whether there is a significant A-a gradient present. 

PaO2 should = FiO2 x 500 (e.g. 0.21 x 500 = 105 mmHg)

Treatment

Mild ARDS (PF 200-300): Consider BiPAP in patients who are awake, alert, protecting their airway and oxygenating/ventilating.

Majority Will Require Mechanical Ventilation

Key Point: Goal is to optimize gas exchange, but avoid barotrauma, volutrauma, atelectotrauma and biotrauma. This is accomplished by low tidal volumes and dry volume status as tolerated.

ARDSnet and Clinical Considerations

http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf  

http://www.ardsnet.org/studies.shtml

1. Tidal Volumes at 4-6ml/kg of IDEAL body weight.

Pro-tip from Evan: Pick your ideal vent mode based on comfort. There are lots of fancy and potentially optimal ventilator modes, such as Bi-level, oscillatory modes, and otherwise. Unfortunately, these are nuanced and can leave to harmful outcomes if doctors and RT’s are not intimately familiar. 

      2. High vs low PEEP tables have not been shown to affect                  mortality.  Must be careful as high PEEP can reduce       cardiac    output.

    3. To maintain the minute ventilation with LTV you must increase the RR.

However, by increasing the RR too much you can cause auto-PEEP.  Thus, permissive hypercapnia can be tolerated unless acidotic (pH <7.15)

1. Auto-PEEP can be measured by measuring the pressure during an expiratory hold and calculating by subtracting the provided PEEP by the total pressure.
2. Maintain plateau pressures below 30. This reduces the amount of volotrauma on patients. Can be accomplished by providing an inspiratory hold and measuring the pressure.
3. Maintain driving pressure below 15. It has been shown to improve mortality. Most likely reduces atelectotrauma.

Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–55.

1. Keep patients DRY – Early pressers as needed. The FACTT trial targeted a CVP <4 lead to an improvement in ventilator free days, an improvement in oxygenation index, less time in the ICU without an increase in shock.

Wiedemann HP, et al. "Comparison of two fluid-management strategies in acute lung injury". The New England Journal of Medicine. 2006. 354(24):2564-75.

1. Consider paralyzing patients with long-acting paralytics (cisatracurium) if desynchrony with the ventilator. The ROSE trial showed no benefit, this is controversial and still a practice by some intensivists.

National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. "Early neuromuscular blockade in the acute respiratory distress syndrome". The New England Journal of Medicine. 2019. 380(21):1997-2008.

1. Can consider APRV which was shown by Zhou et al to improve mortality.

APRV: Essentially a persistent inspiratory phase by ventilator, with “exhallation” phase where the vent triggers “off.” To allow for passive exhalation. Theory is it keeps alveoli open for longer to participate in recruitment and gas exchange and then gives longs a “break.” 

https://emcrit.org/squirt/aprv/

1. Traditional recruitment maneuvers do not improve mortality according to the ART trial.

Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335–1345. doi:10.1001/jama.2017.14171

1. Proning patients substantially improves mortality. Increased recruitment of atelectatic lung according to the Proseva trial

Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159‐2168. doi:10.1056/NEJMoa1214103

1. Consider EARLY for VV-ECMO. ECMO is believed to be potentially a cost-effective measure that increases survival without severe disability at 6 months in patient with severe ARDS. CESAR trial. 

Especially Consider if single organ system is affected in otherwise non-terminal patients

Peek GJ, et al. "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial.". The Lancet. 2009. 374(9698):1351-1363.

Host: Jessie Werner, MD

Guest: Alin Gragossian, DO, MPH

Overview:

In this episode, Dr. Jessie Werner interviews one of EMRA’s 45u45 winners, Dr. Alin Gragossian. As a senior EM resident Alin was diagnosed with heart failure and required an emergent heart transplant. This is the inspiring story that every person should hear!

Special thanks goes to Dr. Shyam Murali (@smuramed), resident at Mercy St. Vincent Medical Center in Toledo, Ohio, for editing this episode!!

Key Resources:

•    Check out Alin’s blog: https://www.achangeofhe.art/

In this episode, Drs. Agboola and Jubanyik discuss Palliative Care in the Emergency Department. They cover a wide range of subjects including: How to deliver “Bad News”, navigating surrogate decision makers, and the “Surprise Question”.

Host: Isaac Agboola, MD, MS

• Yale New Haven School of Medicine, PGY-2
  

Guest: Karen Jubanyik, MD

• Academic Advisor in the Dean of Student Affairs Office
• Past National Chair of SAEM Palliative Care Interest Group
• Associate Professor at Yale New Haven School of Medicine

Key Points:

• “Treat bad news conversations,  just like you would a procedure”
• Palliative Care is an ER doctor’s responsibility because sometimes palliative care is an emergency
• In regards to code status, only offer what options you feel are medically indicated
• Empower surrogate decision makers to make the decision their loved one would want 
• There are over 130 ACGME Hospice and Palliative Care Fellowships that are available if you desire further education in the subject 

References/Resources:

• EMRA Palliative Care Fellowship guide https://www.emra.org/books/fellowship-guide-book/18-palliative-care/
• SAEM Palliative Care https://community.saem.org/communities/community-home?CommunityKey=fc4c2027-6ee3-4bfb-ada7-e1d9e84990ba

• Academic Life in Emergency Medicine- PV Card  http://www.aliem.com/pv-card-palliative-care-screening/

Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health

Guest: Ken Katz MD, FACEP, FAAEM, FACMT, Editor-in-Chief of the EMRA Toxicology Guide, Emergency Medicine Physician with Lehigh Valley Health Network, Professor at the Philadelphia College of Osteopathic Medicine.

Overview:

Seeing an uptick in bleach ingestions? Wondering how to manage that hydroxychloroquine overdose? You are in luck, in this episode, Tiffany talks with Dr. Ken Katz, Editor-In-Chief of the EMRA and ACMT Toxicology Guide. They discuss everything from why and how it was created, the user friendly way it was designed and how it teaches you to think like a toxicologist. We finish up on some advice if you are interested in toxicology and considering a toxicology fellowship. Everything you need to master every tox ingestion.

Suggested References:

• EMRA and ACMT Toxicology Guide
• Goldfrank’s Toxicologic Emergencies
• Tox and the Hound

Key Points:

• The poisoned patient goes hand and hand with the new COVID era; this guide can help you get past those first few steps of resuscitation with confidence.
• Know how to speak to poison control.
• No such thing as medical clearance.
• If you’re interested in toxicology and have that moment where you think, ‘I might want to be a toxicologist,' DO IT!!! It can open doors and career opportunities that you never knew existed.

Dr. Miguel Reyes sits down with EMRA 45 Under 45 winner Salim Rezaie, MD, to discuss how he was nominated and awarded this recognition. How REBEL EM came to be and the future plans for the website, podcast and conference. Additionally, we discuss how to be productive and the power of being 1% better everyday.

Host: Miguel Reyes, MD
@miguel_reyesMD

Guest: Salim Rezaie, MD, FACEP
@srrezaie

Key Resources:

• RebelEM.com

Antibiotics are one of the center pillars of medical management both within and outside of the emergency department (ED). Diagnostic momentum and treatment is established early within a patient’s presentation and is typically initiated in the ED. This places a particular responsibility on us both to initiate adequate treatment for our patients, which is appropriately broad and disease-specific, but also to keep with appropriate antibiotic stewardship.

EMRA*Caster Alex Kaminsky sits down with Dr. Bryan Hayes, ED clinical pharmacist to discuss pearls and pitfalls regarding antibiotic use in the ED - meanwhile dispelling common antibiotic myths and misconceptions along the way.

COVID-19 is affecting all of us in different ways. It can be a challenging time for residents, but you’re not alone. In this episode, your EMRA*Cast hosts share their thoughts and stories as they navigate the constantly changing landscape of ER Medicine during the COVID-19 pandemic.

Host: Jessie Werner, MD

Guests: Isaac Agboola, MD. MS; Tiffany Proffitt, DO, MABS; Miguel Reyes, MD

Key Resources:

• https://rebelem.com/covid-19-the-novel-coronavirus-2019/
• https://emcrit.org/ibcc/covid19/
• https://covid.emrap.org/
• https://www.cdc.gov/coronavirus/2019-ncov/index.html
• https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• https://www.emra.org/external-search/?queryString=covid