424 episodi

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 Podcast - Critical Care and Resuscitation Scott D. Weingart, MD FCCM

    • Medicina
    • 4.9 • 7 valutazioni

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 286 – The Venous Side Matters Too with Phil Rola

    EMCrit 286 – The Venous Side Matters Too with Phil Rola

    We've spoken about the concepts of venous congestion being problematic beyond just pulmonary edema. I've had Phil Rola on in the past to discuss Venous-side issues such as Renal Compartment Syndrome, the Vexus score, and other issues of the under-respected side of the circulation.

    Prior Episodes



    * EMCrit Podcast 240 - Renal Compartment Syndrome - It's all about the Venous Side and We've Been Fracking it up for Years

    * EMCrit Podcast 263 - The Venous Side Part 1 - VEXUS Score with Phillipe Rola



    Today we go further into these concepts, with some concentration on the micro-circulation. There may be quite deleterious effects from iatrogenic volume overload--especially when we are compelled by government regulation to go against our clinical gestalt.



     

    Journal Articles



    * Blood pressure deficits in acute kidney injury: not all about the mean arterial pressure?

    * Renal Perfusion Pressure 60 predisposes to kidney injury

    * There is individual variation on micro-circ from NorEpi

    * CVP affects Microcirc Flow (Editorial)

    * Physiology of the Microcirculation

    * Perioperative Blood Pressure

    * Sublingual Microcirculatory Microscopy



    Special Mention to Ince on Microcirculatory Hemodynamic Coherence



    * Ince hemodynamic coherence





    Now on to the Podcast...

     

    • 17 min
    EMCrit 285 – More on Palliative Care Conversations in Resuscitation

    EMCrit 285 – More on Palliative Care Conversations in Resuscitation

    Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU.



    For more of the amazing Rob Orman, check out the Stimulus Podcast.













    Pearls:



    * When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate.





    * In an ideal world, a DNR order would only affect what you do when a patient’s heart stops.





    * When having a comfort care conversation, Scott uses the dichotomy of two goals:  curative care vs. dignity.



    ___________________________________________________________________________



    Tips and tricks for having a conversation with a patient and/or their family about plan of care:



    * If you don’t have time for the conversation, then reconsider having it.



    * You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice.

    * Deferring the conversation to the ICU is an option.

    * A slapdash conversation is worse than no conversation at all.









    * Create a space where everyone feels comfortable.



    * Provide chairs so people can be seated.









    * Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system.





    * Feel out the situation and try to understand one another. 



    * Your job is to translate the medical realities in a way the family can understand.

    * The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand.

    * 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases.









    * Pick your own philosophy that fits with your strategy and psyche in medicine.



    * Weingart has learned to be medically paternalistic and socially completely open.









    * Inquire:  has the family had prior end-of-life conversations with their loved one?



    * It makes everything easier if they have.

    * If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt.









    * If you feel something is medically inappropriate, state it clearly.



    * This transfers guilt to yourself.

    * In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable.









    * Avoid being manipulative when describing CPR.



    * Don’t tell them chest compressions might break ribs or cause organ damage.

    * Instead, concentrate on the end game and what you could get out of CPR.







    There are 3 tiers of care:  DNR (do not resuscitate), DNI (do not intubate), and comfort care.







    * DNR



    * In an ideal world, DNR would only apply when a patient’s heart is about to stop.





    * While DNR is not supposed to affect the rest of the care we provide, it often does.

    * Being DNR may have significant effects on the willingness of physicians to provide aggressive care,

    • 44 min
    EMCrit 284 – You are the Product – Delete Your Algorithmic Social Media

    EMCrit 284 – You are the Product – Delete Your Algorithmic Social Media

    Algorithmic social media is stealing your joy and may be making your life dramatically worse. If you haven't watched The Social Dilemma, you probably should sit down and give it a view, especially if you have kids.







    Advertising + Algorithm



    Misalignment of incentives



    Business model in which incentive is to find customers ready to pay to modify someone else's behavior



     





    The Algorithm

    Get you to the app and keep you there



    Movie Social Dilemma gets it Wrong



    Negative trumps positive



    Dopamine hit



    Addictive, but mostly shallow or perhaps b/c of shallowness

    Tribalism & Mob Behavior

    Magnification of Fringe Views



    Makes assholes more assholey



    Attention is the reward on social media, and assholery gets the most attention

    Loss of Objective Reality

     

    Individual Apps

    Facebook

    The Worst!!!



    A bunch of you are there so EMCrit has to announce new episodes there

    Instagram

    Just as evil

    Reddit

     

    Twitter

    Sponsored Tweets



    Built to inflict misery and turn people into assholes



    Reub--bring it to Reddit



    Twitter happiness feed

    Youtube

    Turn off "Up Next"

    TikTok

    Insanely addictive

    Netflix

    Algorithm with the right incentives

    The News

    Algorithm



    If you can't change it, don't regard it as important

    Google

    not just creating an echo chamber



    but actually sculpting Truth based on a political agenda



    * Switching over to Hey Email

    * DuckDuckGo



    RSS

    The way to have social media goodness come to you

    Turn off Notifications

    for any social media and for anything else possible

    Go Deep instead of Shallow

     

    If you have kids, avoid social media until ~16

    Jonathan Haidt





    More Stuff to Check Out



    * How to go from being an Ass-hole to an AYS-hole on Twitter

    * 7 Ways to be Insufferable on Facebook

    * How to Use RSS and Itunes to Maximize FOAM Podcasts

    * The Online Hierarchy of Needs - Social Media and FOAM



    Please ReRead 1984



    Now on to the Podcast...

    • 33 min
    EMCrit 283 – Dexmedetomidine (Precedex) – You’d have to be Delirious Not to Use It

    EMCrit 283 – Dexmedetomidine (Precedex) – You’d have to be Delirious Not to Use It

    So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation.

    Upsides of Dexmedetomine (Precedex)



    * No respiratory depression

    * Opioid sparing/analgesic effect

    * Preserves Sleep Architecture

    * Sympatholysis

    * May be delirium-protective

    * May be more hemodynamically stable than propofol

    * Good for neurocritical care



    Downsides of Dexmedetomidine



    * Bradycardia

    * Hypotension (especially when the pt is volume depleted)

    * Cost (much less of an issue now that it is generic)

    * Diuretic effect

    * Slow onset

    * Constipation



    Useful for...



    * Post-intubation sedation

    * NIPPV sedation

    * Procedural sedation

    * Add-on to propofol



    Other Stuff on EMCrit



    * Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)

    * PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?

    * Dexmedetomidine to facilitate noninvasive ventilation



     

    Studies





    The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 - Volume 47 - Issue 2 - p e89–e95)

    https://www.ncbi.nlm.nih.gov/pubmed/21812509

    https://www.ncbi.nlm.nih.gov/pubmed/27035758





    Now on to the Podcast...

    • 15 min
    EMCrit 282 – Hicks on the Labors of Trauma (Blunt)

    EMCrit 282 – Hicks on the Labors of Trauma (Blunt)

    Labors of Trauma (Blunt Ed.)

    So a few weeks ago, I podcasted the Labors of Trauma, a comprehensive list of the responsibilities of a Trauma Team Leader.

    EMCrit 278 - Labors of Trauma - Blunt Edition

    I promised that I was going to do a part II with my co-conspirator, Chris Hicks.

    Hick's Pre-Brief and Leave the Room Checklist





     





    St. Mike's New Trauma Bays



    Calcium



    Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439



    New Hemostatic Resus Ratios



    * Should we add calcium and fibrinogen to our ratios



    New Name for the Pelvic Binder



    * We should be calling these Trochanteric Binders



    Now on to the Podcast...





     

    • 38 min
    EMCrit 281 – Why Can’t Emergency Medicine and Trauma Surgery Just Get Along?

    EMCrit 281 – Why Can’t Emergency Medicine and Trauma Surgery Just Get Along?

    Why Can't Emergency Medicine and Trauma Surgery Just Get Along? This is a question we often ask in the USA given our unique Trauma system. It seems custom built to create conflict in the trauma bay. To explore this issue, I got to talk with Joe DuBose and Bill Teeter. This discussion originally was recorded for Joe's new podcast on Trauma Surgery, Tiger Country. Tiger Country has a bunch of episodes that are worth a listen for ED and ICU folks as well.



    Joe DuBose



    Trauma and Vascular Surgeon at the Shock Trauma Center. Professor of Surgery. Research leader on all things REBOA.



    William Teeter



    Started as a surgery resident, switched over to EM residency and then Crit Care Fellowship. Now an EM Intensivist down South.

    More from DuBose



    * Podcast 170 - the ER REBOA Catheter with Joe DuBose



    Now on to the Podcast...

    • 41 min

Recensioni dei clienti

4.9 su 5
7 valutazioni

7 valutazioni

NoobDoc91 ,

Best EM podcast ever

I've been listening to this podcast for 2 years straight. This show has taught me more on EM and medicine in general than my lest 2 years in med school.
Scott is a fantastic podcaster with incredible communication skills!
As soon as I could, I subscribed to the show to support it and to show my appreciation for everything it has taught me.

cobratom74 ,

Excellent podcast great job

really a great podcast!!

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