current issues in emergency medicine, reviews, opinion and curbside consults
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 RobWhen a patient presents with hematuria, what are the key questions to ask in the ED?
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.
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 painQaseem, 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
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
To get the most out of giving a lecture
Links discussed in this show
P Cubed Presentations Link
Essentials of Emergency Medicine Link
Confound definition
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
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 careHow 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.
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
It's time for a mumps outbreak! Here is a basic primer on the very basic basics.
How do you get mumps?
Incubation period
Presentation
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.
Treatment
Your job
Testing
Testing advanced level
Call the health department
Bottom Line
Links
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
Michelle Lin @M_Lin
Lauren Westafer @LWestafer
Jeremy Faust @jeremyfaust
Jess Mason @Jessmasonmd
Al Sacchetti @Sacchettialfred
Adam Rowh
Anand Swaminathan @EMSwami
Scott Weingart @emcrit
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