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 303 – A Bounceback Case with Mike Weinstock
Mike Weinstock comes on the show to discuss a case from a chapter of his brand new book: Bouncebacks Critical Care. We go through the case and the key decision points. I think you will love it!
Read the Full Chapter from the Book
Bouncebacks Crit Care_CHAPTER 11 - 63 yo man fall SOB
Get the Book
Now on to the Podcast...
EMCrit 302 – Pain Management Update with Sergey Motov
Today an update on pain management in the ED. Sergey is a great friend and a previous guest on the show when he discussed the Opioid-Free ED.
Sergey Motov, MD
Sergey is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is a Research Director who is passionate about safe and effective pain management in the ED. He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.
The Pain-Free ED
Sergey has an amazing site, with resources and lectures: The Pain-Free ED
A Brief Discussion of the Advantages of Morphine over Hydromorphone and Fentanyl from a Euphoria Perspective in Patients with Intact Organs
This is far more an issue for what you send these patients home on.
Sergey recommends MSIR tablets 7.5-10 mg Q 6 hrs for 3 days for most acute pain indications in patients without organ failure. There is also liquid 10 mg/5 ml, so 1/2 tsp gets you 5 mg.
Consider diclofenac gel in the appropriate patient. Now available over the counter. Apply twice/day.
Giving Fentanyl For Longer Duration Pain Means the Patient will be in Pain Again Soon
* Consider a regimen that matches the duration of pain
* Do Not Use Morphine
* Hydromorphone--avoid in ESRD, If you feel the need to use it in more mild renal failure, Drop Dose by 75% and extend dosing regimen
* In the ED, you should probably use Fentanyl. Still reduce dose by 75% of standard and extend dosing intervals
* When you need to send the patient home, do not use tramadol. Mild to moderate, use oxycodone with sig. dose reduction. In the future, buprenorphine may be the agent of choice.
* Very low dose morphine, but probably the better idea is:
* Fentanyl with a dose reduction and interval extension
* For sending a patient home, Oxycodone consider half dose with extension of intervals
* Recent trial compared 0.15 mg/kg to 0.3 mg/kg with no difference
* Breath-Actuated Nebulized Ketamine
Sergey does not Like IM Pain Meds
* Causing pain to relieve pain doesn't make a ton of sense
More from Sergey
* More on Kidney and Liver Failure Pain Management
* Pain Pearls on Opioids
* Handout on Analgesics for Hepatic and Renal Failure
Do a Virtual Resus Fellowship
Resus Leadership Academy
Now on to the Podcast...
EMCrit 301 – The Five Fears with Rob Orman (Mind of the Resuscitationist)
“Fear is beneficial. It happens for a reason. Everything we have in our heads is evolutionarily beneficial for the most part. The benefit of fear is it allows you to predict the evil sh*t that's going to happen and avoid it.”
This is another episode from Rob Orman's Stimulus Podcast. Rob is my best buddy and the best interviewer in the business. In this episode, we discuss:
The distinction between carrying fear and being afraid
Good doctors carry fear with them. Those who don’t carry a healthy dose of respect for the risks of their actions can be dangerous.
Fear should be your friend. It should be one of many internal voices that you listen to and to which you decide whether you want to regard or ignore.
Fear should not be your limiter. “If fear is your primary internal theme, then you're afraid. And that's a problem.”
The importance of embracing the idea that sick patients don’t take a joke
The sicker the patient, the less room you have for error. Be very careful.
The Five Fears
1. Scott’s fear number one: lawyers
This is a healthy fear as long as you use it the right way. Shared decision-making and good documentation help to keep this fear positive.
It’s a bad fear if it prompts you to practice defensive medicine and do things that patients don’t need or want (such as order unnecessary tests or procedures).
When you document, be sure to show that you thought of the life-threatening diagnosis and why you did not think it was the cause of the patient’s complaint.
2. A common fear that Scott does not personally experience: being an imposter
This is the inner voice that says negative things about your performance and capability of getting the job done.
Scott’s mindset has always been to assume that his baseline skill level at anything is zero until there is external calibration. With this cognitive assumption, he has never had an inner voice speaking negatively to him.
In emergency medicine there are plenty of opportunities to externally calibrate your skill set (eg. following up on patients to see if your diagnosis was correct or keeping a log of your first-pass intubation success rate).
3. Fear of Monday morning quarterbacking
This is a useful fear to have because it allows you to foreshadow what you're going to experience tomorrow and the chance to fix the situation today.
While Monday morning quarterbacking can yield strategies for improvement when done in a positive fashion, it can also be done badly and be an opportunity to serve insults.
“The fear of Monday morning quarterbacking should drive your documentation more than it drives your practice.” And if you can anticipate what the Monday morning quarterback is going to harp upon, it should drive you to take actions to have the appearance of due diligence.
4. Fear of procedural complications
Procedural complications can be prevented by breaking them down into distinct micro skills that can be individually mastered.
No matter how adroit one is at procedures, having a certain level of fear of the potential complications is healthy. That fear makes you question whether the procedure is truly necessary, or whether it would be safer done in another setting such as the OR.
EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle
Create a Goal
Safe First Pass Success (sFPS)
An Airway Quality Assurance Program Improves First Pass Success without Desaturation
* What is good FPS
* Emerg Med Australas 2017;29:40
* Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.
* 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71
Creation of an Airway Lead
One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)
* Watches every intubation
* Conducts CQI / Reviews every Intubation that went Awry
* Lit Watch
Development of a Debrief Form
This form allowed a review and quality improvement process for every intubation.
Development of an Airway Database
If you are not measuring, I promise you, you are not doing well
A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.
Use of a Validated Failed Airway Algorithm
A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)
Development of an Airway Note
Key aspects of management: CL, story behind the airway
Standard Operating Procedure
No everyone cannot have their own way of doing things
Perfect Preox and Preintubation Optimization
We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized
Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.
VL for all First Passes
At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.
* Maximize FPS
* Maximize Learning
* Maximize Teamwork
* Maximize Reflection
Standard Geometry Video Laryngoscopy as Standard
Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.
Recordings and Videographic Review of All Intubations
EMCrit 299 – Bougie Masterclass with George Kovacs
If you are not using the bougie for your intubations then you are leaving first pass success on the table. Today, George Kovacs on how to use the bougie, aka the tracheal tube introducer. This is a remix of two lectures from Georges amazing AIME Airway Project. If you want to hear the full version, click on over to George's Youtube (Part 1 & Part 2).
George discusses when to use the bougie, how to use the bougie, and the part that I liked best, advanced bougie techniques.
More Bougie on EMCrit
* EMCrit Guest Post – Bougie Lessons from the Literature and Experience by George Kovacs
* EMCrit Guest Post – Drawing Circles for Bougie Hangup by Neil Dasgupta
* EMCrit Podcast 226 - Airway Update - Bougie and Positioning
Now on to the Vodcast...
EMCrit 298 – Calcium in Exsanguinating Patients with Ricky Ditzel and Jeffrey Siegler
Something I have been preaching for a decade has finally gotten the attention and research it deserves. On this episode, I get two of the authors from the Lethal Diamond Paper to discuss hypocalcemia in the bleeding patient.
Prior Special Operations Combat Medic and current Premed Postbacc Student at Columbia trying to go to medical school
EM Doc & EMS Physician at Wash U in St. Louis
Read the Lethal Diamond Paper
* Official JTACS Lethal Diamond
Here is a powerpoint from Ricky
The Lethal Triad Should be the Lethal Diamond
Calcium is an independent part of the death spiral, but it is also intertwined with the other three factors as this diagram demonstrates:
Calcium in Clotting
from @MikeEMPharmD data from: Giancarelli A, Birrer K, Alban R, Hobbs B, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187. [PubMed]
What to Do
* Give calcium with your first unit of blood in trauma (and TXA)
* Consider giving 1g for every 2-4 products you administer during large transfusion
* Send and Respond to Icals
Read these Papers
* Citrate in Cirrhotics
* Hypocalcemia during MTP
* mass trans
* Howland WS, Schweizer O, Carlon GC, Goldiner PL. The cardiovascular effects of low levels of ionized calcium during massive transfusion. Surg Gynecol Obstet 1977; 145:581.
* Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187.
* Retrospective Study
Related EMCrit Stuff
* EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)
* EMCrit Podcast 13 – Trauma Resus II: Massive Transfusion
* Massive Transfusion Protocol (MTP)
Now on to the Podcast...
Love the lecture by Dr Sara Crager!
Love the lecture by Dr Sara Crager on RV failure! Best Lecture I’ve heard on RV failure.
Great ER podcast! I look forward to episodes.
Dr. Weingart is amazing! He is talented in the way he delivers his information and teaches. I’m an ER trauma nurse and I have found this podcast so helpful and I look forward to listening to every episode.
Labors of blunt trauma is my favorite episode of all time! It’s a great review for highly experienced Trauma nurses and super beneficial for new trauma nurses. I’m waiting on the labors of penetrating trauma.
Ed & trauma nurse here, I love this podcast. I work in a rural hospital with a busy ED, this podcast gives supplemental and pertinent information that has both improved the care I provide and helped me grow as a nurse. Relatable to many levels of health care providers, in many different fields and departments.
Have also seen much of this podcast implemented at work... even joking with my coworkers saying “Scott Winegart here” when suggesting something I learned on this podcast. Always gets a good laugh... because we ALL listen to this. 👍🏼
Thank you Scott! Keep it up, I love this stuff!