Rob Orman, MD

Podcast Overview

current issues in emergency medicine, reviews, opinion and curbside consults

Podcast Episodes

Peeing Blood and the Pesky Erection

Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer.

Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised. 

Stuff Adam and Rob have discovered recently and are really digging Rob
  1. Dermastent
  2. Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls of heavenly delight I use during shifts (and home, and exercise, and so on). 
  3. This Tono-Pen
  1. Wearing gloves while eating a sandwich
  2. Topical TXA for a persistently bleeding biopsy site in a patient taking rivaroxaban
  3. Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in the nebulizer basin either with or without bronchodilator
Treating Priapism
  1. Patient presents with persistent painful penile erection.
  2. Anesthetize the penis, sterilize the area of corpus cavernosum you are going to drain. How one numbs the penis for this procedure is a matter of great debate, meaning there is no best answer. Some espouse a dorsal penile nerve block while others favor local anesthesia at the site of injection. I prefer local infiltration at the site of injection and have found it to be more reliable than trying to get the whole penis numb.
  3. Mix up a solution of dilute phenylephrine. This is your vasoconstrictive agent. The end goal is to dilute 1mg of pheynylephrine with 10 mL of normal saline (or 9.9 mL if you're a purist). This gives a concentration of 100mcg/mL ( the recommended dose from the American Urologic Association is actually 100-500mcg/mL, giving a significant margin of error). The phenylephrine you have in your department is most likely 10mg/mL, so you will end up drawing a tenth of a mL.  Getting the vasoconstrictive agent mixture correct seems to be one of the more anxiety provoking aspects of this procedure.  There are lots of ways to make your mixture, the most straightforward method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB syringe. Into that same syringe, draw up 0.9cc of saline. Now you have a total of 1cc total volume. Add that to 9cc of saline and you are at the desired 100mcg/mL concentration. When you've got this task completed, set this syringe to the side. You're going to need it shortly. Pro tip: label the syringe after creating the dilute phenylephrine.
  4. Attach an 18 or 19 g butterfly needle to a large syringe
  5. Inset the butterfly needle into the corpus cavernousum at the lateral base of the penis. It doesn't matter which side, each side connects to the other. Your entry point is either 10 or 2 o'clock. Pull back on the syringe while advancing the needle. Once you get blood back, stop- that is your needle depth for the remainder of the procedure. Pro tip: Even though you might be tempted to use the biggest syringe you can find, like a 60cc behemoth, stick with a 20cc syringe. The bigger syringe might create too much suction, which can ruin the day.
  6. Aspirate blood. This will look thick and dark (chocolate syrup, old motor oil dark). The amount you'll be able to aspirate varies, but it's usually  around 10-20cc.
  7. Keep the butterfly needle in place while you  unscrew the aspiration syringe from the proximal port and replace it with your syringe with dilute pheynlephrine. Better yet, use a 3 way stopcock. On one port, you have your vasoconstrictive agent ready to go. On the other port, you can easily work the replacement of fresh aspiration syringes. Having an assistant for syringe management makes this process much easier (and safer as you're less likely to change the position/depth of the butterfly needle while fiddling about with the syringes)
  8. Inject 1mL of dilute phenylephrine into the penis. Pro tip that's probably not actually a pro tip: After injection, massage the penile shaft to get more diffuse spread of the vasoconstrictive agent. Does this massaging actually improve outcome? Unknown.
  9. The penis may now become flaccid or it may still be tumescent. If the erection does not resolve, repeat steps 6 through 8. This may take several rounds of aspiration and injection of vasoconstrictive agent.
  10. When is the penis flaccid enough that you can stop? Some say when the blood aspirated, others when the penis stays flaccid. There's not an absolute demarcation line, it's more of Justice Potter Stewart's "I know it when I see it."
  11. Milk the penis from tip to base to squeeze out residual blood. The patient can do this as well. Pro tip: After you've finished the above steps, wrap the penis in a compressive bandage like an ace wrap or Coban to prevent reaccumulation of blood.
  12. If you are unable to resolve the priapism with this technique, urology may need to take the patient to the OR

When a patient presents with hematuria, what are the key questions to ask in the ED?

  1. Is there any associated pain? If so, you may be dealing with a stone, infection, etc.
  2. If it is painless, which is the most common situation we see, the big question is whether or not the patient is in CLOT RETENTION. Are they retaining urine or can they pee freely? The test for this is a post void residual bladder scan
  3. If they are peeing blood, but not in clot retention, they can follow up with urology as an outpatient for CT urogram, cystourethrotgam, and advanced urine testing
  4. If they are in CLOT RETENTION, you need to drain the bladder. What often gets placed is a three way catheter. These catheters are great for irrigating the bladder, but may not be sufficient to evacuate clots.
  5. Dr. Shaffer recommends placing a 22 Fr 6 eye catheter. Here's an example of a 6 eye catheter (we have no connection with the company selling these in the link provided)
  6. Once the 6 eye catheter is in, hand irrigate the bladder until there are no clots
  7. If the urine clears (cranberry colored or lighter), pull the catheter and give a voiding trial
  8. If the urine is still bloody, NOW place a 3 way catheter and admit the patient for continuous bladder irrigation. They get admitted to see if they go back into clot retention.
  9. Jess Mason and urologist Eamonn Bahnson have a master class review of placing the difficult foley in the August 2017 edition of EMRAP.
Interstitial cystitis
  1. Evaluate for and treat infection
  2. Manage pain
  3. Make sure they're on an anticholinergic
  4. Follow up with urology


When Breath Becomes Air. Lucy Kalanithi Interview

Last summer I took a road trip to Canada and during the drive I listened to the book When Breath Becomes Air. That was a year ago, and I still think about that book, almost daily. When Breath Becomes Air is the autobiographical account of the final 2 years of neurosurgeon Paul Kalanithi life. Paul was in residency, age 36,  when he was diagnosed with stage 4 lung cancer, to which he ultimately succumbed. The book tells the tale of the nuts and bolts of his treatment, his transformation from doctor to patient, but more importantly, it was about time. His time was limited, just like all our time is limited, but with a terminal diagnosis, in the face of death, he asked the question, “What makes life worth living?” What do you do with your time, what’s important? Do you work if you’re physically able, do you spend all of your remaining time with your family? Time can feel infinite, especially when you’re young, but as individuals, time is our most precious resource, and it’s a nonrenewable resource. So how do you spend it?

Paul died before completing his manuscript and his wife, Lucy Kalanithi, a Stanford internist, put it together and wrote the epilogue. Since then, she’s become a passionate a vocal advocate for helping others choose the heath care and end of life experiences that best align with their values.  In May 2017, at Essentials of Emergency Medicine in Las Vegas, I sat down with Lucy for a live interview on why she does what she does, some of the experiences she and Paul when through, how her perspectives on life and medicine have changed, what she thinks when she sees a patient with the sniffles, what if everyone died like a doctor, and reframing the question where there is a devastating diagnosis or even a run of bad luck from, “Why me?” to “Why not me?” I’d encourage you to listen to this particular podcast episode all the way through and not in small chunks. It builds momentum as the conversation progresses and at the end, culminates in what are some beautiful words of wisdom...Life is not about avoiding suffering.

Spring 2017 Journal Club

It may be summer (in the northern hemisphere), but that doesn't mean we can talk all the goodness that was our spring journal club. As usual, Adam Rowh slayed the beer selection with a killer Scottish ale as well as these lovely articles. Enjoy....

The papers Less is more for low back pain

Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530.

Full article link


How worried should you (and the patient) be about discharge glucose?

Driver, Brian E., et al. "Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia." Annals of emergency medicine 68.6 (2016): 697-705.

Full article link


Ibuprofen and fracture healing

DePeter, Kerrin C., et al. "Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?." The Journal of emergency medicine 52.4 (2017): 426-432.

Full article link via Broome Australia's favorite ginger raconteur, Casey Parker


Ketorolac's therapeutic ceiling

Motov, Sergey, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial." Annals of Emergency Medicine (2016).

Full article link from, yep, once again, Casey Parker


Concussion, Rest, and the 8th Dimension

Grool, Anne M., et al. "Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents." Jama 316.23 (2016): 2504-2514.

Full article link

Thomas, Danny George, et al. "Benefits of strict rest after acute concussion: a randomized controlled trial." Pediatrics (2015): peds-2014.

Full article link

How to learn from a lecture

Amal Mattu stops by to talk about the best way to get the most from attending (as well as giving) a lecture. Hint, it's not the the transfer of information. Amal says that lectures have one of two purposes: to persuade or  inspire.

To get the most out of attending a lecture

  • take notes
  • no more than three take home points per talk
  • when you get back home, review your notes and read the handout, source material, etc
  • ask questions if possible
  • do not sit passively and try to absorb information by some sort of osmotic wizardry

To get the most out of giving a lecture

  • simple slides without too much or complex information
  • no more than one take home point every 10 minutes
  • engage the audience in the discussion
  • repeatedly reinforce the take home points
  • practice and then practice a bit more


Links discussed in this show

P Cubed Presentations Link

Essentials of Emergency Medicine Link

Confound definition

Examining mental health patients

When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental health part of the exam, what do you look for and how do you document it? There are all sorts of different ways to go about it, but one I find particularly useful is the mental status exam. Not alert and oriented times 3 or GCS 15 mental status exam, but the one that goes by the title Mental Status Exam.


It’s an exam that is carried out by your powers of observation. There is no stethoscope, no palpation involved. You are just watching and listening. What we’re going to go through is my adaptation of the full Mental Status Exam. It’s been tweaked, added, subtracted, and modified over the years and I’ve found it helps to break down the aspects of a patient's appearance and behavior in a way that makes sense (at least to me). As I was putting this podcast together, I thought about some of the dogma that goes into any structured evaluation, meaning: these are the core elements of the exam and that’s all there is to it; it’s always been done this way and this is the best way. But there really is no evidence that performing a mental status exam in one particular way versus another improves outcome. The same could be said for many parts of the physical exam. Much like the suicide risk assessment template I use, I see this as a way to make sense of what is often an incredibly complex emergency department presentation. 


ED Mental Status Exam

The constituent elements are: Mood, affect, eye contact, attending to internal stimuli, thought process and content, speech pattern, grooming, and presence or absence of suicidal ideation. Let’s break that down piece by piece.

Mood and affect. These terms are confusing because they are synonyms and don’t they kind of mean the same thing? Think of it this way: mood is how the patient tells you they’re feeling and affect is what you observe. For example, mood: I am anxious, I am depressed, I am crawling out of my skin, etc. Affect: what do you observe about their emotional state. Do they appear anxious, depressed, flattened, blunted, restricted, is their affect exaggerated? Is it congruent with their mood and the current situation?

Eye contact. Do they look you in the eye, are they engaged in the conversation? Are they withdrawn and looking down/away?

Attending to internal stimuli. This is something we usually equate with a psychotic state: auditory and/or visual hallucinations. It’s being generated by their mind as opposed to an external force. Sometimes it’s pretty clear. They’re intently looking around in an empty room or carrying on a conversation when there’s no one there. Sometimes it can be more subtle and only manifested as inattentiveness with latency in answering a question or following an instruction (although that latency can have many other causes).

Thought process and content.  Is their thought pattern organized or disorganized? Are there delusions or obsessions?

Speech. Is it normal content and cadence? Pressured? Super loud or super soft? Is it tangential? Tangential speech is often categorized as a thought process because it is a variant of disorganized thought, but I put it here because it's such a distinct speech pattern.

Grooming: Well kempt? Disheveled? Clothing encrusted with urine and feces?

Suicidal ideation: Present, absent, passive, active with a plan?

There are many other parts of the full Mental Status Exam, but those are the high yield aspects that I use, or at least start with. Some things like 'insight' I put in the suicide risk assessment, because that takes an involved conversation with more direct engagement to tease out, rather than easily observe.

Putting it all together.

A person who is having no issues at all, completely normal exam. 

Mood, baseline and neutral per patient. Affect, neutral and congruent with mood. Eye contact good. He does not appear to be attending to internal stimuli. Thought process and content normal. Answers all questions appropriately. Speech is normal content and not tangential. Grooming well kempt. Suicidal ideation denies.

Or a psychotic patient may have an exam that looks something like this. 

Mood is depressed. Affect flattened. Poor eye contact. He appears to be attending to internal stimuli and is looking about the room during our conversation. He periodically turns his head to the side and yells obscenities. Thought process is disorganized and there are several seconds of latency in answering questions. There is a delusion of persecution where the patient reports being followed by the government. Speech is slowed cadence, tangential, and he gives answers that are not always relevant to the question. Grooming disheveled. Suicidal ideation: Patient does not answer questions regarding this, but presents after attempting to jump of an overpass.

This evaluation will be different for every patient and the findings aren't always easy to describe, but I find that having a standard framework makes assessment consistent, exponentially easier, and more thorough.


Mentioned in this episode

Suicide Risk Assessment master page

Essentials of Emergency Medicine

Nasal suction. Miraculous simplicity

It is bronchiolitis season my friends. Even I have a bit of the URI. When we’re talking bronchiolitis, the conversation is almost always about: do steroids or bronchodilators work, what to do with a touch of hypoxia. Important conversations to be sure, but the highest yield pearl I have ever received about bronchiolitis (or any pediatric URI for that matter) was given to me by pediatric emergency physician Andy Sloas. Wash it out, suck it out. 


We know that babies are obligate nose breathers. When that nose is plugged, breathing is harder and they don’t eat. When they don’t eat, they get sicker. They cycle continues until they get dehydrated and REALLY sick.

Sometimes a baby with a stuffy nose who isn't eating just needs a little nasal clean out. They breathe easier, they start to eat, or drink (which is usually the case) and often can go home without any other treatment.

So if a child has a URI with a runny nose and isn’t feeding, squirt in some saline and suction out the boogers. The key is in the home care. Most parents will tell you that they’re suctioning with the little bulb suction, but they can benefit from a structured approach.

Home care

How often to suction?

Breakfast, lunch, dinner and right before bed. 

Saline drops

Before suctioning, squirt in some saline drops. You can give the parents some drops or they can buy them from the pharmacy. 

Squirt in the saline drops. The child might cough. They might cough, swallow mucus, and vomit after some saline drops. All that nasal goo getting swallowed can make kids vomit, and that’s expected. Not desirable, but it happens. First saline drops, then suction. The parents might not be able to get mucous with each suction and that’s OK. It’s the repeated attention that matters.

Here is an example of a discharge instruction for runny nose treatment. 

To help clear nasal secretions (nasal mucus and runny nose) spray over-the-counter saline nasal spray (or drops) into each nostril morning and night and with each feeding. After this, suck out each nostril with a bulb suction. Spraying in the saline spray will help clear the nasal mucous and loosen it up so that it can be better suctioned. Your child may gag or cough after the saline is sprayed in the nostrils, this is not unexpected. Keeping your child’s nasal passage open will help them breathe easier and make it easier for them to eat and drink.


Disclaimer: This is only an example of phrasing for discharge instructions. It is not meant as medical advice. Please see site disclaimer for further details.

Articles you need to know - winter edition

There's a journal club in my living room every few months (or at least there will be - this was the first). Raconteur Adam Rowh, MD joins the show to talk the med lit we dissected by the fireside.
Stuff in this show

  • Prandoni, Paolo, et al. "Prevalence of pulmonary embolism among patients hospitalized for syncope." New England Journal of Medicine 375.16 (2016): 1524-1531. Link
  • Righini, Marc, et al. "Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study." Jama 311.11 (2014): 1117-1124. Link
  • Wang, Ralph C., et al. "Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis." Annals of Emergency Medicine (2016). Link
  • Sakles, John C., et al. "First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department." Academic Emergency Medicine 23.6 (2016): 703-710. Link
  • The Bell Tolls for Renal Colic CT Link


It's time for a mumps outbreak! Here is a basic primer on the very basic basics.

How do you get mumps? 

  • Respiratory secretions, that guy sitting next to you on the airplane with the huge parotid gland and just sneeze in your eye. Not good.

Incubation period

  • How long does this need to cook before mumps is ready for full star spangled disease manifestation? Somewhere between 2-3 weeks.


  • The classic presentation is a swollen parotid gland. Usually it’s both, but in a quarter of patients, it’s unilateral parotitis, which can make things tricky when you’re wondering if this patient has acute bacterial parotitis, or mumps. The other salivary glands can swell as well, but much less commonly than the parotid. 
  • All this salivary swelling business may be preceded by a few days of viral syndrome fever , headache, body aches, feeling crappy.  Patients feel bad for a few days, the parotids swell, stay swollen for anywhere from 2  to 10 days. There may, however, be no parotid swelling as well, just a viral syndrome and nothing else (there may also be no symptoms). 

The other issues with mumps

Orchitis. Can be one testicle, can be  both testicles. Females can also have reproductive organ involvements- less than 1% with oophoritis and a similar rate for mastitis. Non reprotrducgei or salivary gland involvement include aseptic meningitis and pancreatitis.

But wait, I can’t get mumps, I’ve been vaccinated. 

  • Unfortunately that’s not 100% protective and sadly, immunity can wane. 


  • There is no specific treatment, just supportive care.

Your job 

  • Your job now is to keep it from spreading. In the hospital, droplet precautions. Mumps is most infectious from 2 days before the parotid swelling to at least 5 days after. Hard to quarantine when there's no parotid swelling, but once it starts, 5 days of no school, no work, and separated from family members (not always possible).


  • We’re getting these recommendations from the health department to collect samples from almost every body fluid, but isn’t blood enough? It turns out that it is not. Serum IGM, which you’d expect to see in an acute infection, may be falsely negative, especially in someone who has been vaccinated. Many different tissues are infected in mumps, so to really figure out if it’s mumps or not, we’ve been advised to get serum, urine, and buccal swabs. By the time the results come back, your patient will probably be finished with quarantine, but from a public health angle, you’re a hero.

Testing advanced level 

  • In unvaccinated patients, IgM is present by day 5 post onset of symptoms. In a vaccinated person, there might not be any IgM and it could have a very quick spike and disappearance. When you get that IgM mumps test back negative 3 weeks after you’ve seen the patient,  just know that that doesn’t mean they don’t or didn't have mumps. 
  • Why buccal swabs? This tests for the mumps virus itself and is very good in the early stage of infection, especially in someone who has had vaccination, which is hopefully everybody, but it’s not. 
  • Why urine testing? Not as sensitive as buccal testing in early infection but currently recommended in our region. I’m guessing to cast as wide a net as possible. 

Call the health department

  • Initiate patient tracking, contact tracking, and have a public health expert take over with following up on test results etc. 

Bottom Line

  • If you see a patient with parotid swelling and there has been a viral prodrome, or perhaps there’s been a mumps outbreak - think mumps. If you have high suspicion, immediately  initiate droplet precautions, collect samples, call the health department, quarantine (at home) and if possible separate from family for 5 days following onset of parotid swelling. Sometimes that last part is not possible, but have them do their best.


  • Specimen Collection (what to order, exact way to collect it). Link
  • Oregon Public Health Mumps Review (mumps overview). Link
  • Oregon Public Health Mumps Main Page (investigative guidelines, case report form). Link
  • CDC Mumps Pinkbook Review (mumps overview) Link
  • CDC Mumps mainpage Link
  • CDC Current Mumps Outbreaks Link

Practice Changers

What were your practice changers in 2016? For me, it was Reuben Strayer's simple phrase for when to give epinephrine in allergic reaction patients: For A, B, or C,  give E. If there is involvement of airway, breathing ,or circulation, give epi. It seems simple when it's spelled out this way, but there can be a lot of hemming and hawing when deciding to give (or not to give) this drug. The other, less clinical, pearl is something learned from former Google engineer Chade-Meng Tang: pick two random people and think, "I hope that person is happy." That's it, just think it, don't have to do anything else. The results are astounding. Now let's hear what our guest panel has to say about what changed their practices in 2016....


Simon Carley @EMManchester

  • ALTE is now BRUE
  • Nitrous oxide can cause spinal cord degeneration
  • Impact Brain Apnea


Michelle Lin @M_Lin

  • Uses isopropyl alcohol to treat nausea and vomiting


Lauren Westafer @LWestafer

  • Elevates the head of the bed to 30-45 degrees when intubating


Jeremy Faust @jeremyfaust

  • Recommends E-Cigs as an option for patients trying to quit smoking


Jess Mason @Jessmasonmd

  • REVERT trial
  • Double sequential awake intubation- video here
  • PATCH Trial
  • Trigger Point Injections - video here


Al Sacchetti @Sacchettialfred

  • Use ultrasound to confirm foley catheter placement


Adam Rowh

  • PATCH Trial
  • Richard Feynman “So my antagonist said, "Is it impossible that there are flying saucers? Can you prove that it's impossible?" "No", I said, "I can't prove it's impossible. It's just very unlikely". At that he said, "You are very unscientific. If you can't prove it impossible then how can you say that it's unlikely?" But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible.”


Anand Swaminathan @EMSwami

  • Azithro is losing potency against Strep Pneumo
  • The EKG findings in PE
  • Pre-charge the defibrillator during CPR
  • Use the pelvic binder properly
  • Use the oxygen wave form to confirm pacemaker capture
  • Shared decision making


Scott Weingart @emcrit

  • Be careful with hyponatremic patients


If you are on Twitter, there's a good chance you've seen commentary from our guest today Sassy MD. She is a 4th year medical student and gives an unfiltered commentary on the trials and tribulations of med school, life, deciding what shoes to wear, and even the internal dialogue about her attendings.


In this episode

  • using twitter for mentorship
  • interview advice on how to answer "what is your greatest weakness"
  • integrating 'nontraditional' education into early learning
  • the importance of textbooks
  • the side of emergency medicine you don't learn on rotations (it's the clerical duties!)
  • choosing a specialty

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