Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.
EMCrit 296 – The French Connection, Part 1 – Resuscitation Geography, Logistics, & Ergonomics
After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.
James French, MD
Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.
Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.
In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him. To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.
James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk) as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.
In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.
In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur,
EMCrit 295 – Resuscitation Room Readiness
We need to be able to respond instantly to the sickest patients rolling into the resus bay--sometimes with no warning at all.
but no need to put things away
EM Docs are good at prep bad at breaking down
from Precision Medical
Flex Tip Bougie, Intubation Stylet for Hyperangulated Blade
Orange Tackle Boxes
Igel 4, Scalpel, Bougie, DuCanto Suction
SCRAM Resus Bag
Needs to be Set-Up
SCRAM Rx Lite
Defib with Pads
Art Line Set-Up
Two Great Virtual Conferences
Essentials of EM
Go Here for early bird discount before April 5th: Register for EEM
Bring Me Back to Life: Le Show
www.Bringmebacktolife.ca and use the password "Le show" for a $100 discount
Now on to the Podcast...
EMCrit 294 – Acute Crit Care Grand Rounds with Josh Farkas
Anyone who reads EMCrit knows PulmCrit and therefore its creator, Josh Farkas. We had him for virtual grand rounds at Stony Brook EM recently. This is the 1 hr GR--and it was fantastic!!!
See the Video Version
Here is the Audio-Only Version
EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR)
What is a Heuristic?
A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics.
Thinking Fast and Slow
System 1 vs. System 2
Our interview with Gary Klein
ERADs are the Action Version of Functional Heuristics
Emergency Reflex Action Drills from Lauria
Jerk & Check
Never immediately act on a heuristic. Have your kneejerk response and then use System 2 to Check
Functional Heuristics in Resuscitation
Flank Pain in Elderly is AAA until the Ultrasound
Severe Bradycardia/Heart Block = Hyperkalemia until you see the K
Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)
Unexplained Hypotension gets antibiotics
Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic
Chest Pain Plus
Tamponade is dissection until it is not
Old stay, young go
Err towards Young D/C and Old Stay and then check
Think LP/do LP
The diagnoses of costochondritis and gastroenteritis do not exist
What is going to kill this patient? (Pre-Mortem)
a adaption of Gary Klein's idea
Ad Spot: Butterfly IQ+
Read about and watch Mike Stone demonstrate BiPlane
EMCrit listeners get a free case worth $99 with the purchase of a Butterfly iQ+ probe and membership. Simply use the referral code "EMCRIT" at checkout
Note: Butterfly provided a probe for testing to Metasin LLC
Now on to the Podcast...
EMCrit 292 – IV T3 for Myxedema Coma, A Different Take with Eve Bloomgarden
So we recently did a Myxedema Episode with Arti Bhan. On the show, we were supposed to have a 2nd endocrinologist, but due to scheduling issues, it didn't work out. For a different take on IV T3, today we have that endocrinologist on the show.
Eve Bloomgarden, MD
Dr. Eve Bloomgarden, MD is an endocrinologist at Northwestern Memorial Hospital and an assistant professor in the Division of Endocrinology, Metabolism and Molecular Medicine at Northwestern University Feinberg School of Medicine. Dr. Bloomgarden received her medical degree from New York University and completed residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Bloomgarden’s clinical expertise is in the diagnosis and management of thyroid disorders and thyroid cancer as well as general endocrinology. She is a clinician educator and contributes to the medical education of students, residents, and fellows. She loves spending time with her husband, also a physician, and their two young children. The COVID crisis has brought out her social media voice and her strength as an advocate for her fellow healthcare workers.
If the Patient Looks Crappy...
This is when to consider combined therapy in Dr. Bloomgarden's practice
Always Give Steroids First
I think this is even more critical if you are using LT3
Combined LT4/LT3 Dosing Strategy
LT4 200-300 mcg
LT3 5-10 mcg IV then 2.5-5 mcg q8 hrs (until pt stabilizes and then switch to just LT4)
American Thyroid Association Guidelines
* Guidelines from American Thyroid Assoc.
21c. In patients with myxedema coma being treated with levothyroxine, should liothyronine therapy also be initiated?
Given the possibility that thyroxine conversion to triiodothyronine may be decreased in patients with myxedema coma, intravenous liothyronine may be given in addition to levothyroxine. High doses should be avoided given the association of high serum triiodothyronine during treatment with mortality. A loading dose of 5–20 μg can be given, followed by a maintenance dose of 2.5–10 μg every 8 hours, with lower doses chosen for smaller or older patients and those with a history of coronary artery disease or arrhythmia. Therapy can continue until the patient is clearly recovering (e.g., until the patient regains consciousness and clinical parameters have improved).
Weak recommendation. Low-quality evidence.
Not Many Patients Treated with LT3 in this Review
Japanese Review of Treatment Options for Myxedema
Want More Eve?
* Check her out on the Curbsiders
More Myxedema and Thyroid on EMCrit
* IBCC chapter & cast - Myxedema coma (decompensated hypothyroidism)
* Decompensated Hypothyroidism ("Myxedema Coma")(Opens in a new browser tab)
* Thyroid Storm(Opens in a new browser tab)
* Podcast 149 – Thyroid Storm
EMCrit 291 – For Frak’s Sake, Ketamine is at least as Hemodynamically Stable as Etomidate!
Terren Trott, MD
Emergency Medicine + Ultrasound + Critical Care Physician + Airway Enthusiast. Editor for 5minuteairway and critical care now.
The Original Crit Care Now Blog Post
Terren's Post on Critical Care Now
The Two NEAR Database Papers on Ketamine Hemodynamics
* Mohr et al.
* April et al.
Jabre RCT on Ketamine vs. Etomidate
* KetaSED - Jabre Lancet RCT
* Bottom Line KetaSED Summary
* Reanalysis of Jabre demonstrating that all intubations were done by EM in ED or EMS Environment
Now on to the Podcast...
A bit over my head at times as someone who works primarily in a remote center, but still worth listening to.
One of the Best EM Podcasts Around
Fantastic, succinct, high-level, topic-focused critical care podcast for emergency physicians and residents. Scott Weingart is a well-informed evidence-based educator who's not afraid to combine his critical appraisal of the literature with his anecdotal experience and medical knowledge. Thanks for the great content and pearls.
Thank you for all your hard work.
Here's the thing: Scott Weingart can punch me in the face and you know what? I would thank him. He would then expertly assess any damages to my facia bruta and fix them masterfully. Amazing, informative, entertaining, and inspiring. On a somewhat serious note, my life has recently imploded, and keeping Weingart's voice in the background of my personal chaos has helped immensely. This calming voice, and yet there is an urgency, which makes sense….so many patients, many of them so very sick. Also, his voice reminds me of Dennis Miller (I hope you take this as a compliment), and I like to imagine him strolling the hallways of his hospital, and if something gets in his way, he retaliates with "Hey, I'm walkin' here, I'm walkin'!"