PEM CHATT

Episode Summary

In this special adult EM edition recorded at the AAENP conference in Nashville, Toni sits down with Jill Ogg-Gress, DNP, APRN-NP, FNP-C, ENP-C, who presented "The Silent Emergency: Managing Fever in the Immunocompromised Population." Jill explains why immunocompromised patients can look deceptively well, why a "low-grade" temperature should still trigger a full workup, and why these patients shouldn't wait in the waiting room. The conversation covers the four high-risk patient groups, the initial lab workup, how procalcitonin fits in, when to consider an LP, empiric antibiotic choices, and the value of the ED pharmacist.

Biggest Take-Home

Recognize who these patients are and don't delay the evaluation. Get them back, get labs going, and start antibiotics within the first hour so they have better outcomes down the road.

Timestamps

Disclaimer

Any opinions expressed on this podcast are solely those of the speakers and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians; always consult your physician leader when appropriate. Any cases discussed have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may represent composites of clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.

This podcast is designed for medical education purposes only. The speakers have made every effort to provide current, evidence-based information; however, this should never replace your own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm discussed may not reflect those of your healthcare system and may vary by geographic location or employer. This podcast is not intended to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911.

Title: When Ear Pain Is a Red Flag: Recognizing Necrotizing Otitis Externa

Episode Description:

What happens when a routine ear infection becomes a potentially life-threatening diagnosis?

In this episode of PEM CHATT, recorded at the AAENP conference in Nashville, we welcome Jill Ogg-Gress to discuss a memorable case of necrotizing otitis externa.

An older, immunocompromised patient initially diagnosed with otitis externa returned to the emergency department just three days later with worsening symptoms, hearing loss, and facial droop. What initially raised concern for stroke ultimately led to the diagnosis of necrotizing otitis externa with early osteomyelitis.

Jill shares the clinical clues that prompted further investigation, the importance of recognizing cranial nerve involvement, and why early imaging findings may not tell the whole story.

In This Episode:

Clinical Pearl:

A patient with otitis externa who develops disproportionate pain, hearing loss, or cranial nerve abnormalities needs reassessment for invasive infection. A CT without obvious bony erosion does not necessarily exclude early necrotizing otitis externa.

The Takeaway:

Sometimes the most important diagnostic skill is recognizing when the initial explanation no longer fits.

Listen to PEM CHATT for practical conversations and clinical insights from emergency medicine professionals.

Disclaimer: This podcast is intended for healthcare professional education and does not replace clinical judgment, institutional protocols, or specialist consultation.

25 | The Untrustworthy Normal with Rachel Cody, DNP, AGACNP-BC, FNP-BC, ENP-C

Recorded live at the AANP Conference, Nashville, Tennessee

A normal lab can feel like permission to relax. Sometimes it is. Sometimes it is the most dangerous result on the chart.

In this conference episode, Toni sits down with Rachel Cody to recap her AANP lecture, "The Untrustworthy Normal." They talk about why labs often lag behind pathology, why every test you order should answer a specific question on your differential, and why a clinician's gut is real clinical data. Rachel walks through a sepsis case where a normal white count and a normal lactate gave false reassurance, and she explains why some diagnoses, like necrotizing fasciitis, will never be made by a lab.

The bottom line: treat the patient, not the numbers.

Clinical Pearls

Timestamps

Disclaimer

Any opinions expressed on this podcast are solely those of the speakers and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians; always consult your physician leader when appropriate. Cases discussed have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may be composites of clinical experiences. This podcast is for medical education only and does not replace your own review of current evidence-based practice. Pathways or algorithms discussed may not reflect those of your healthcare system. This podcast does not provide medical advice. If you have a medical concern or emergency, see a local medical provider or call 911.

24 | Tick Paralysis: Easy to treat but easy to miss with Toni Dobson, DNP, FNP-C, ENP-C

⏱️ Runtime: about 13 minutes

📝 Episode Summary In this conference-series episode, Toni steps into the role of both host and guest to share her AAENP presentation on tick paralysis. It's a rare neurologic presentation in the emergency department and one that ED clinicians often miss. Toni explains why: she had it on her differential, searched the patient for a tick and still missed it.

The episode covers how tick paralysis develops and who's most at risk. Toni walks through a pediatric case of acute-onset ataxia, builds a differential and shows how to tell tick paralysis from Guillain-Barré syndrome (GBS). She also shares a practical ED algorithm that starts with a thorough skin exam.

LINK to algorithm: https://drive.google.com/file/d/1Ld-3mh1m89_dVaFo82CtCS-oqQa3xll7/view?usp=sharing

⏰ Timestamps

00:00 Intro

00:18 Welcome and the AAENP conference series

00:39 Why tick paralysis, and why it gets missed

01:24 What tick paralysis is: the tick, the toxin and the timeline

02:25 Ascending paralysis, mortality and treatment

02:59 Who's at risk

03:23 Why ED clinicians miss it

04:15 The case: a 3-year-old with acute ataxia

05:53 Building the differential

07:19 Tick paralysis vs. GBS

09:31 The ED algorithm 10:14 The skin exam and the flea comb

11:00 After the tick is removed: observe, then discharge or admit

11:32 When symptoms don't improve

12:13 Take-home points

13:05 Disclaimer

⚖️ Disclaimer Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians. Always consult your physician leader when appropriate. Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional. This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may have discussed may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site. This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call nine one one for assistance.

23 | Delivering Difficult News with Cory Edgar, DMSc, PA-C

Host: Toni Dobson

Delivering bad news is not a "soft skill" — it is a core clinical skill that can be learned, practiced, and improved. In this episode, Toni sits down with Corey Edgar to walk through the SPIKES protocol, a structured framework for difficult conversations. Corey breaks down each step with practical ED examples, explains why the warning shot and the pause matter so much, and reminds us that bad news is not only cancer or death. Anything that changes a patient's or family's anticipated future counts — which means most of us deliver bad news on every shift.

🔑 Key Takeaways

⏰ Timestamps

⚖️ Disclaimer

Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians. Always consult your physician leader when appropriate. Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.

This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may have discussed may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site. This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911 for assistance.

📍 Special Adult EM Edition, Live from the AAENP Conference in Nashville, Tennessee

🎧 Host: Toni Dobson

In this special adult emergency medicine edition of PEM CHATT, Toni talks with Brandy Ganatra at the AAENP conference about SCAPE, or sympathetic crashing acute pulmonary edema. This is the patient many of us learned to call "flash pulmonary edema." Brandy covers the pathophysiology behind the newer name, how to recognize these patients quickly, why high-dose nitroglycerin is the mainstay of treatment, and why early, aggressive management in the ED can turn a crashing patient around in minutes.

SCAPE is sympathetic crashing acute pulmonary edema, the presentation many clinicians know as "flash pulmonary edema."

The term is fairly new. Cardiology often calls it acute decompensated heart failure, but critical care and ED literature increasingly use "SCAPE."

The name points to the pathophysiology, and the pathophysiology points to the treatment. Think bigger than "the lungs are full of fluid."

A sympathetic surge causes marked peripheral vasoconstriction and a sharp rise in systemic vascular resistance (SVR), which is the afterload the left ventricle has to pump against.

The core need is afterload reduction.

Extremely tachypneic and tachycardic

Profoundly hypertensive

Hypoxic and tripoding, with severe respiratory distress

Pink, frothy sputum from acute pulmonary congestion

Onset is sudden. "It happens in an instant."

Common history: heart failure or hypertension, sometimes with missed medications

💊 Nitroglycerin is the mainstay of therapy.

Lower doses mostly cause venous dilation, which is why nitro is used for angina and ischemia.

SCAPE calls for high doses. Brandy starts IV nitro at 100 mcg/min and may titrate up to 400 mcg/min.

One sublingual nitro tablet is roughly equal to 80 mcg/min, which puts the IV dosing in perspective. "It's not as scary as we think."

Nitro has a short half-life (about 2–5 minutes). Titrate down instead of turning the drip on and off.

😮‍💨 Support breathing at the same time. Use non-invasive ventilation (CPAP/BiPAP) for the high work of breathing, with the goal of avoiding intubation.

🔀 Do things in parallel, not one at a time. We like our ABCs, but here several interventions need to start together.

📋 A practical sequence:

Give sublingual nitroglycerin.

While you do that, set up non-invasive ventilation.

While you do that, prepare to start IV nitroglycerin, then titrate.

With timely afterload reduction, restored cardiac output, and breathing support, these patients can turn around in 15–20 minutes. 🔄

👀 Recognize it early, monitor closely, and treat aggressively. Timing and the right management are critical.

🤝 Teamwork is essential.

🚫 Don't get stuck on diagnostics. Don't wait for a chest X-ray to confirm it. Put the POCUS probe on 🔍 and look for volume overload.

💪 Act quickly and with confidence. Current literature supports high-dose nitroglycerin as safe and effective in the ED.

[00:00] Intro: special adult EM edition from the AAENP conference

[00:18] Meet guest Brandy Ganatra

[00:39] What is SCAPE, and why the new name?

[01:28] How bedside management has changed: getting comfortable with high-dose nitro

[02:41] Recognition: what these patients look like

[03:17] Nitroglycerin dosing: low vs. high dose, starting at 100 mcg/min

[04:00] Nitro safety: short half-life, and sublingual compared with IV

[04:50] Turning patients around in 15–20 minutes

[05:12] Take-home points: teamwork, POCUS, and acting with confidence

[05:44] Closing and disclaimer

Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system.

In many states, advanced practice providers work collaboratively with physicians. One should always be careful to consult with their physician leader when appropriate.

Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.

This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may discuss may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site.

This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911 for assistance.

21 | Submersion Injuries with Dr. Sarah Lazarus

In this episode of PEM CHATT, host Toni Dobson is joined by pediatric emergency physician Dr. Sarah Lazarus to break down the critical topic of pediatric drowning and submersion injuries. Together, they explore real-world clinical scenarios, debunk common myths, and provide practical guidance for both clinicians and caregivers.

Drowning remains one of the leading causes of death in children, particularly ages 1–4, and even non-fatal events can result in devastating long-term consequences. This episode emphasizes both clinical management and prevention strategies—highlighting how quickly these events occur and how often they happen despite close supervision.

🔑 Key Takeaways

⚠️ Clinical Pearls

🧠 Myth Busting

“Dry drowning” isn’t real.

🛟 Prevention Insights

Resources and references:

Timeline

00:00 Welcome to PEM CHATT

00:19 Why Drowning Matters

01:12 Meet Dr. Sarah Lazarus

02:14 Bread Pudding is my favorite

03:34 Drowning Terminology

04:38 Who Is Most at Risk

06:08 Silent Drowning Explained

09:15 Systemic Effects Checklist

11:03 Fresh vs Salt vs Cold

11:46 Three Patient Categories

12:36 Case One Asymptomatic Kid

14:12 Avoiding Unneeded X-Rays

16:12 Case Two Symptomatic Infant

18:40 Imaging and Labs Strategy

18:58 When to Skip Antibiotics

20:02 Arrest Scenario Walkthrough

20:30 Resuscitation Priorities And ECMO

21:54 When Resuscitation Is Futile

22:40 C-Spine Immobilization Debate

23:24 Drowning CPR Starts with Breaths

25:29 Injury Prevention Work and Stats

27:14 Layers of Drowning Prevention

30:01 Dry Drowning Myth Busting

33:16 Key Pearls and Closing

In this “Rewind” episode, Toni sits down with retired pediatrician Dr. Margaret “Meg” Wang, who trained and practiced through the pre-vaccine and early-vaccine eras of pediatrics, including the 1989–1990 measles epidemic in New York City. Together, they walk us through what pediatrics looked like before Hib, pneumococcal, varicella, and rotavirus vaccines and what we might face again as vaccination rates fall and herd immunity wanes.

You’ll hear vivid, frontline stories of:

Clinically, Toni and Dr. Wang dig into:

🔑 Key Takeaways:

📌 Call to Action:

Hit play, then share this episode with a colleague, resident, or trainee who has never seen these diseases and thinks of measles or chickenpox as “mild.” Their future patients are counting on it. 💉🧠

Fever Management in Children 3-36 Months: An Evidence-Based Approach

Join host Toni Dobson and guest Andrea Perkins, PA-C, as they dive deep into the evidence-based management of fever in otherwise healthy children aged 3-36 months. This comprehensive episode covers everything from basic fever physiology to algorithmic approaches for both vaccinated and unvaccinated children.

Key Topics Covered:

Defining fever and understanding the pathophysiology

The critical difference between fever and hyperthermia

Vaccination status and risk stratification

Comprehensive physical exam pearls

Evidence-based algorithms for immunized vs. unimmunized children

UTI risk assessment and when to obtain urine samples

Laboratory workup guidelines based on vaccination status

Fever management strategies and parent education

Addressing fever phobia in families

Resources:

UTI Calculator: www.uticalc.com

UpToDate management guidelines: UpToDate Link

Andrea's algorithm: Link to Algorithm

Next Episode: Dr. Margaret Wang joins us to discuss the return of vaccine-preventable illnesses and how we can prepare.

📺YouTube: https://www.youtube.com/@PEMChatt

🟢Spotify: https://open.spotify.com/show/6oaYDeq5AXIZGxBvEIxaTs

🍎 Apple Podcasts: https://podcasts.apple.com/us/podcast/pem-chatt/id1806882767

In this episode of PEM CHATT, the focus is on febrile neonates, the first part of a two-part series on pediatric fever management. Host Toni speaks with Dr. Lindsay McHale, a pediatric emergency medicine physician, to discuss how historical protocols for managing febrile neonates have evolved with advances in vaccines, PCR testing, and maternal surveillance. The discussion covers the 2021 AAP guidelines for managing febrile neonates, the essential components of a fever workup, interpretation of test results, and the nuances of decision-making across neonatal age groups. Practical insights on performing lumbar punctures, antibiotic selection, and interpreting potentially confounding results, such as bloody CSF taps, are shared, along with real-life case examples that illustrate the complexities involved. The conversation aims to equip clinicians with an evidence-based approach to improve patient outcomes in various clinical settings.

#PEM #NP #APP #PA #pediatrics #emergencymedicine #emergencynursepractitioner #fellowship #medicaleducation #podcast #children #nursepractitioner #clinicalpharmacists #febrileneonate #sickbabies #lumbarpuncture

00:00 Introduction to Febrile Neonates

00:57 Historical Management of Febrile Neonates

01:25 Advancements in Medicine and New Guidelines

02:23 Introducing Dr. Lindsay McHale

03:56 Defining Febrile Neonates

04:54 Managing Febrile Neonates in the ER

05:51 Cold Babies and Controversies

07:45 Treating Fever in Neonates

09:06 Inclusion and Exclusion Criteria for Febrile Neonate Protocol

10:27 Why Neonates Are High-Risk

11:40 Code 60: Rapid Response for Febrile Neonates

12:30 Hypothetical Case Study: Febrile Neonate

14:24 Parental Concerns and Communication

19:57 Detailed Workup and Testing

23:27 Antibiotic Choices for Neonates

25:13 Dosing Nuances in Neonatal Antibiotics

26:49 Tips for Performing Lumbar Punctures

30:25 Interpreting Test Results in Neonates

32:46 AAP Sepsis Protocol for Neonates

40:06 Managing Febrile Infants: Case Studies

44:18 Conclusion and Next Episode Preview

LINKS:

AAP Guideline https://publications.aap.org/pediatrics/article/148/2/e2021052228/179783/Evaluation-and-Management-of-Well-Appearing?autologincheck=redirected

CHOP Algorithm

https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway

THE MISFITS

 https://drive.google.com/file/d/1gpUsQOxMlbuqI-6hBDcZEF5ckpJWhWWb/view?usp=sharing