EMDOCS.net hosted me on Ask Me Anything

The great folks at emdoc.net had me on to do an Ask Me Anything. It was great fun:



  Ask Me Anything with Scott Weingart (10/13/2014) 
9:02
Baker Hamilton: 

Welcome to AMA with Scott Weingart – Dr. Weingart is here and we’ll be starting up in just a minute. Feel free to start asking questions!

Monday October 13, 2014 9:02 Baker Hamilton
9:10
[Comment From guestsguests: ] 

What are some ways to “practice critical care in the ED?” are there any steps that we can take to become better at it without going to a fellowship?

Monday October 13, 2014 9:10 guests
 
Scott Weingart: 

I don’t think a fellowship is necessary. More than anything it is a mindset. It requires an absolute dedication to doing everything necessary to stabilize the sick patient, even at the expense of the well patients who may complain or feel slighted.

  Scott Weingart
9:12
[Comment From ChrisChris: ] 

Can you tell us some ways to help break into the critical care scene?

Monday October 13, 2014 9:12 Chris
 
Scott Weingart: 

Chris, can you clarify your level at this stage and what you mean by breaking in. Do you want to lecture, produce FOAM, simply participate in the conversation, etc.

  Scott Weingart
9:15
[Comment From GuestGuest: ] 

Hey Scott! thanks for doing this…I’m an APD trying to redo our Journal Club education…What is your ideal way to do journal club for residency education? Do you like small groups? focus on EBM? landmark articles?

Monday October 13, 2014 9:15 Guest
 
Scott Weingart: 

think these folks are nailing it
http://emed.wustl.edu/educa…

personally I hate small groups (but this may not be a totally pedagogically sound assessment)
I want to hear what everyone has to say. I love the idea of assigning multiple articles in order to find truth rather than just learn how to analyze an article. I like journal clubs where we try to find an answer to a clinical question rather than assess an article. St Emlyn’s also kills it.

  Scott Weingart
9:20
[Comment From GuestGuest: ] 

What are three articles every ed doc should know cold?

Monday October 13, 2014 9:20 Guest
 
Scott Weingart: 

wow great and tough question. I’ll answer for every resuscitation doctor
1. PIOPED I
2. TTM Trial
3. Any of the Croskerry cognitive biases in EM papers

  Scott Weingart
9:23
[Comment From Alex KoyfmanAlex Koyfman: ] 

What are 3 EM myths you’d like to see go away?

Monday October 13, 2014 9:23 Alex Koyfman
 
Scott Weingart: 

#1 far and away is that it is ok to intubate a patient and then do anything else except give a bunch of analgesia before sedatives

#2 along the same lines, it is ok for a patient to be left in excruciating pain when they are unstable

#3 It is acceptable for any other specialty to dictate how we practice in our own department

  Scott Weingart
9:23
[Comment From ChrisChris: ] 

For a more senior attending…who is unable To go back for fellowship but maybe id like to start lecturing on crit care topics…

Monday October 13, 2014 9:23 Chris
 
Scott Weingart: 

Chris, I am the wrong person to ask. My path was a one-off and total happenstance.

  Scott Weingart
9:24
[Comment From Alex KoyfmanAlex Koyfman: ] 

What are 3 ways your clinical practice has changed in the past few years?

Monday October 13, 2014 9:24 Alex Koyfman
 
Scott Weingart: 

easy
1. I was a strict follower of EGDT in 2002 and by 2014 I use none of it
2. 36 instead of 33 for post-arrest
3. Apneic oxygenation is a game changer

bonus: ECMO, ECMO, ECMO

  Scott Weingart
9:26
[Comment From GuestGuest: ] 

RE: myth #2….so for your borderline hypotensive trauma patients with moderate to severe injuries..how are you controlling pain in the trauma bay? (assuming they DON’T need to be intubated)

Monday October 13, 2014 9:26 Guest
 
Scott Weingart: 

Special K baby. fentanyl as well, see my discussion with Rick Dutton: http://emcrit.org/podcasts/…

  Scott Weingart
9:27
[Comment From GuestGuest: ] 

as a resus doc…are you afraid that palliative care is going to put you out of business? jk… Seriously, how have you incorporated it into your practice?

Monday October 13, 2014 9:27 Guest
 
Scott Weingart: 

hell no. Any resus doc is a palliative care doc. Maximally aggressive care always, whether curative or palliative. the former without the latter makes you a monster

  Scott Weingart
9:28
[Comment From Alex KoyfmanAlex Koyfman: ] 

Has your sepsis care changed in the past few months?

Monday October 13, 2014 9:28 Alex Koyfman
 
Scott Weingart: 

no. we’ve been doing a version of arise and process for the past 3 years in the NY STOP Sepsis collaborative I co-chair. We have ~22% ARR of death in 15,000 patients.

  Scott Weingart
9:30
[Comment From HH: ] 

What roles can folks in FOAMed universe have in the duty to warn others (and ourselves) from overembracing FOAMed as a substitute in critical literature review?

Monday October 13, 2014 9:30 H
 
Scott Weingart: 

biggest worry I have right now. FOAM is spoon-feeding of info. It should inspire reading, not doing. I have residency directors tell me that residents are doing crazy stuff and then saying they heard it on a podcast. I think it is a valuable use of resident conference time to review FOAM and see if it translates to the individual program and how to do it

  Scott Weingart
9:31
[Comment From GuestGuest: ] 

I’m a community doc w/o ECMO…I’ve never seen it before in my entire life. what are some things EVERYONE should know about ECMO?

Monday October 13, 2014 9:31 Guest
 
Scott Weingart: 

it is coming as the solution to persistent arrest, post-arrest cardiac stunning, and may replace mechanical ventilators entirely. come to our site edecmo.org

  Scott Weingart
9:32
[Comment From Alex KoyfmanAlex Koyfman: ] 

Would love to hear about the latest data you collected on DSI and is there anything you’d tweak?

Monday October 13, 2014 9:32 Alex Koyfman
 
Scott Weingart: 

trial will be published in the next 3 weeks. 62 pts, no complications, self-controlled. in the critical desaturaters every single one of them improved their sats. no tweaks. just expansion to hemodynamic dsi–give the ketamine first in shock patients to see what it does

  Scott Weingart
9:33
[Comment From GuestGuest: ] 

by “baby”…I hope you know I’m a grown man with a beard.

Monday October 13, 2014 9:33 Guest
 
Scott Weingart: 

come to NYC, we’ll school you on the creative uses of language : )

  Scott Weingart
9:35
[Comment From Alex KoyfmanAlex Koyfman: ] 

How do you approach teaching the honing of skills to picking up high risk disease w/ a low prevalence?

Monday October 13, 2014 9:35 Alex Koyfman
 
Scott Weingart: 

it is a shit-show. let’s just get it out there. these conditions should be missed or we should accept an enormous amount of overtesting. Our society should issue a statement that missing PE, dissection (of any vessel), nec fasc, unless the pt presents with totally classic symptoms, should be considered the standard of care

  Scott Weingart
9:35
[Comment From Sam GhaliSam Ghali: ] 

Hey Scott,

Monday October 13, 2014 9:35 Sam Ghali
 
Scott Weingart: 

hey brother

  Scott Weingart
9:36
[Comment From Alex KoyfmanAlex Koyfman: ] 

What’s your approach to managing the bleeding unstable pt who is taking novel oral anti-coagulants?

Monday October 13, 2014 9:36 Alex Koyfman
 
Scott Weingart: 

xabans get 4-factor PCC, though we don’t know if there is in-vivo reversal of the bleeding. Pradax-who knows. Janus general still gives the 4 factor, but I have no idea if it works. FEIBA is probably better for Pradaxa. There will be insanely expensive antidotes for all of them very soon and we will use those.

  Scott Weingart
9:37
[Comment From JamesJames: ] 

I have $10,000 to use for CME by October 2015. How should I spend it?…give me good advice because whatever you say…I’m doing.

Monday October 13, 2014 9:37 James
 
Scott Weingart: 

easiest question in the world. SMACC 2015 in June in Chicago. It will be the best conference in all of resus and I don’t get a dime from them. smacc.net.au

  Scott Weingart
9:40
[Comment From Alex KoyfmanAlex Koyfman: ] 

Can you discuss a few tips in the care of the Critically Ill Morbidly Obese pt?

Monday October 13, 2014 9:40 Alex Koyfman
 
Scott Weingart: 

My bud Haney Mallemat has a great lecture on this on free em talks.

Biggest tip is good ramping for airway management, changes an impossible airway to a doable one:
http://www.airwaycam.com/Ea…

use a bougie with the first attempt

beyond that, most of them need scans and only a few of them fit. super easy to miss stuff. most need admit even if you can’t figure out why.

i think we are failing these folks on the psych end. there is usually an underlying problem and this is just as much a path to suicide as the tylenol od

  Scott Weingart
9:41
[Comment From Tim G from ChicagoTim G from Chicago: ] 

If you have a patient that comes to your ED with signs of “possible Ebola” from triage nurse…who are you sending into that room? med student, junior resident, senior resident, nurse or just yourself?

Monday October 13, 2014 9:41 Tim G from Chicago
 
Scott Weingart: 

scares the shit out of me, but I think its got to be me. i can’t imagine captaining the ship any other way. but like i said I am petrified. we are supposed to be a real healthcare system and we are treating the situation like amateurs.

  Scott Weingart
9:44
[Comment From Alex KoyfmanAlex Koyfman: ] 

What are 3 patient populations we struggle with that we can do better with?

Monday October 13, 2014 9:44 Alex Koyfman
 
Scott Weingart: 

In the ED
the post-intubation pt
the demented, elderly sick pt
the neurocritical care pt that doesn’t immediately leave the dept

  Scott Weingart
9:44
[Comment From Tim G from ChicagoTim G from Chicago: ] 

Do you invest in any medical/health care related stocks? if so, how do you go about picking companies?

Monday October 13, 2014 9:44 Tim G from Chicago
 
Scott Weingart: 

i know my limits and i am not smart enough nor do i have the time to figure this stuff out. all money is indexed

  Scott Weingart
9:45
[Comment From GuestGuest: ] 

Do you have any tricks for nailing EJs? I feel like they are hit or miss. I usually just have the patient lay flat and drop head of bed….sigh

Monday October 13, 2014 9:45 Guest
 
Scott Weingart: 

start a peripheral deep vein in the arm or a central line, that’s all i do anymore–ej is too sketchy

  Scott Weingart
9:45
[Comment From Mike StoneMike Stone: ] 

hey brother, want to come work my night shift? if not, I guess I’ll have to wait to see you in Chicago

Monday October 13, 2014 9:45 Mike Stone
 
Scott Weingart: 

sure, be right over

  Scott Weingart
9:46
[Comment From Alex KoyfmanAlex Koyfman: ] 

how do you successfully teach the EM mindset to your residents?

Monday October 13, 2014 9:46 Alex Koyfman
 
Scott Weingart: 

it is all modeling and giving them the space to be able to do what’s right. i’ve worked in 3 hospitals and all of them had dedicated staff, nurses, and space solely for the care of the critically ill in the first hours of arrival. without that it is all lip service

  Scott Weingart
9:48
[Comment From Sam GhaliSam Ghali: ] 

Hey Scott- I hope you’re well my friend. You are up there with the most intense and dedicated guys. Wondering if you’d like to share any major burnouts you’ve had and how you dealt with it?

Monday October 13, 2014 9:48 Sam Ghali
 
Scott Weingart: 

there were a few years right after my first fellowship where I started my new job with all of the most cutting edge knowledge of trauma that could be packed into 1 eager skull. I arrived to a group of surgeons (at Janus General) that told me a patient is too sick for the OR, that ATLS is the way we practice, and that ED docs shouldn’t open chests. Happily the leadership changed and everything became better, but I hated trauma for a few years. My fellowship was in Trauma Critical Care. If not for the great medical cases I may have had to leave practice at the Janus

  Scott Weingart
9:49
[Comment From Rob BryantRob Bryant: ] 

What advice do you give to your graduating residents re: keeping up & continuing to provide great care?

Monday October 13, 2014 9:49 Rob Bryant
 
Scott Weingart: 

you need to read everything you can your hands on. that will do it. everything flows from there. i can tell you the great docs, easily–they are always reading. sine qua non

  Scott Weingart
9:50
[Comment From Alex KoyfmanAlex Koyfman: ] 

do you still use Normal Saline as a resus fluid?

Monday October 13, 2014 9:50 Alex Koyfman
 
Scott Weingart: 

i use whatever matches best to the patients current acid-base/neuro status. NS is the way to go for brain injury or vomiting patients

  Scott Weingart
9:50
[Comment From Mike StoneMike Stone: ] 

Thanks! Your comment is awaiting moderation.

Monday October 13, 2014 9:50 Mike Stone
 
Scott Weingart: 

: )

  Scott Weingart
9:51
[Comment From Mike StoneMike Stone: ] 

Single highest yield use of ultrasound in your practice? The sonogeeks want to know…

Monday October 13, 2014 9:51 Mike Stone
 
Scott Weingart: 

RUSH Exam or any exam that gives me an answer to why my pt is hypotensive (FAST Comes in at #2, but i have less i can do with the info)

  Scott Weingart
9:52
[Comment From Alex KoyfmanAlex Koyfman: ] 

I’m particularly interested in how you think we can do better w/ the neurocrit care pt…

Monday October 13, 2014 9:52 Alex Koyfman
 
Scott Weingart: 

sick heads don’t take a joke. even one perturbation (hypoexmia, bp, hypercapnea) and their chances of survival decrease sharply. these folks need 1:1 nursing an an attending seeing only a small cohort of other pts.

  Scott Weingart
9:52
[Comment From GuestGuest: ] 

should I upgrade to Yosemite?

Monday October 13, 2014 9:52 Guest
 
Scott Weingart: 

upgrade from what

  Scott Weingart
9:54
[Comment From "Rick James""Rick James": ] 

How are you working to become a better bedside doctor. Can you give specific measures you are taking?

Monday October 13, 2014 9:54 "Rick James"
 
Scott Weingart: 

i’ve always admired the docs that take their residents back to the bedside after presentation and redo the physical exam in tandem. i am trying to do that more and more. i am also rereading Sapira’s the art of physical diagnosis and trying to reintegrate that lost knowledge

  Scott Weingart
9:54
[Comment From HH: ] 

Any suggestions on methods to appraise FOAMed itself as what has been done for publications?

Monday October 13, 2014 9:54 H
 
Scott Weingart: 

my friend Brent Thoma and his colleagues have worked up a schema that should be published shortly. it is the best thing out there

  Scott Weingart
9:55
[Comment From Ben CooperBen Cooper: ] 

In light of process and arise, what’s your take on when transfusion and/or inotropy is appropriate in sepsis?

Monday October 13, 2014 9:55 Ben Cooper
 
Scott Weingart: 

transfusion is easy < 7g /dl. Inotropy if you have given fluids and raised the MAP to 65 and the heart still looks crappy on echo.

  Scott Weingart
9:57
[Comment From SteveSteve: ] 

How do you keep yourself from ordering too many CT PE scans? What is your step by step approach…(details please)

Monday October 13, 2014 9:57 Steve
 
Scott Weingart: 

always ask yourself if you think the pt has >2% chance of PE. if not and you write that in your note and why, that should be enough to stop. then always PERC. then always d-dimer unless high. still in the running then ct. here is the algo: http://emcrit.org/misc/imag…

when acep states age-adjusted is ok, will do that as well

  Scott Weingart
9:58
[Comment From Alex KoyfmanAlex Koyfman: ] 

Describe a scary case you had recently / something you struggled w/?

Monday October 13, 2014 9:58 Alex Koyfman
 
Scott Weingart: 

had a N-bomb patient that continued to get worse no matter what we did. scariest drug out there in my opinion. every organ system shut down.

  Scott Weingart
9:58
[Comment From MattMatt: ] 

Do you ever use pressors in severe, isolated, TBI, without systemic hypotension?

Monday October 13, 2014 9:58 Matt
 
Scott Weingart: 

you need to get the cerebral perf pressure >55-60. i have no problem at all reaching for norepi at the drop of a hat to make that happen

  Scott Weingart
9:59
[Comment From Dan BDan B: ] 

any tips for a successful application to ED training programs?

Monday October 13, 2014 9:59 Dan B
 
Scott Weingart: 

3 ways to get an interview
1. do a rotation at that shop
2. get a letter from someone the program directors know and trust
3. kick ass on the boards

once you have an interview, you must come across as someone i want to drink a beer with or what’s the point of having to hang with you for 4 years

  Scott Weingart
10:00
[Comment From ChrisChris: ] 

Who do you like to take the World Series?

Monday October 13, 2014 10:00 Chris
 
Scott Weingart: 

what is the world series

  Scott Weingart
10:02
[Comment From Alex KoyfmanAlex Koyfman: ] 

how have you been able to diversify your career and carve out time for the things you love?

Monday October 13, 2014 10:02 Alex Koyfman
 
Scott Weingart: 

i love my boy, my wife, and my friends. the rest of it has blended with my career. i don’t advocate this path

  Scott Weingart
10:03
[Comment From SanjaySanjay: ] 

how do you keep yourself from micromanaging residents?

Monday October 13, 2014 10:03 Sanjay
 
Scott Weingart: 

i only work critical care, i owe it to my patients to be on top of everything. i think with em residents, they want this level of interaction–the learning opportunities are already too scarce. we’re starting a fellowship–that will be tough to find how much leeway i can give the fellows to muck things up before stepping in

  Scott Weingart
10:04
[Comment From GuestGuest: ] 

Scott, just wanted to say that you’ve completely redirected my passion and focus for critical care–your passion has made my time at an otherwise impossibly small community ICU tolerable!

Monday October 13, 2014 10:04 Guest
 
Scott Weingart: 

can’t thank you enough for those kind words

  Scott Weingart
10:05
[Comment From JBJB: ] 

When applying for a faculty job..what are some things I should DEF watch out for when screening positions?

Monday October 13, 2014 10:05 JB
 
Scott Weingart: 

smartest move you can make (nobody ever does this) is to just shadow an existing attending during the night shift for 3 or 4 hours. gives a realistic vision of what your life will be like. med studs do this to decide on 3 years of their life, we go in cold for a potential decade long stint

  Scott Weingart
10:07
[Comment From JohnJohn: ] 

From a medical legal standpoint…what are some things we should ALWAYS document in a crashing patients note…and some things we should NEVER write down.

Monday October 13, 2014 10:07 John
 
Scott Weingart: 

i guess there should be a description of the thought process for why the ABCs were not maximally controlled if you didn’t intubate, secure the airway, etc.

never blame the consultants for stupidity in the record–can get you fired, but make it clear that you advocated maximally for your patient when the fault rests on their shoulders

  Scott Weingart
10:08
[Comment From EMFoamerEMFoamer: ] 

who are your ED mentors? what makes them a great mentor?

Monday October 13, 2014 10:08 EMFoamer
 
Scott Weingart: 

Tom Scalea is the doc I want to be when I grow up. Peter Deblieux made me want to pursue ED Critical Care. Manny Rivers showed me that Upstairs can be brought Downstairs.

  Scott Weingart
10:08
[Comment From SamSam: ] 

Any books not on your suggested reading list you are recommending to your residents?

Monday October 13, 2014 10:08 Sam
 
Scott Weingart: 

Getting Things Done by David Allen will change your life

  Scott Weingart
10:10
[Comment From JohnJohn: ] 

thinking back, what are the top 3 things you wish you had known or mistakes you made when starting your ED ICU / Resus unit?

Monday October 13, 2014 10:10 John
 
Scott Weingart: 

bring nurses into every major decision from Day 1. Took me 2 years of fights to figure that out. Any time someone tells you that you can’t do something,find a way to show that your pt needs it and have them offer you a valid alternative–most times there is none.

  Scott Weingart
10:11
[Comment From Alex KoyfmanAlex Koyfman: ] 

Best case over past month?

Monday October 13, 2014 10:11 Alex Koyfman
 
Scott Weingart: 

We had an eclampsia case at the Janus where I had to interact with OB, Anesthesia, multiple nurses from other services, and neurology. Everyone worked together, not a single fight or wasted moment. The medicine was not complex, but I left that shift feeling like a million bucks.

  Scott Weingart
10:12
[Comment From Alex KoyfmanAlex Koyfman: ] 

Thoughts on lactate in sepsis; we’ve all had those crazy sick folks w/ a nl lactate…

Monday October 13, 2014 10:12 Alex Koyfman
 
Scott Weingart: 

it is actually very rare. there will be pts that are crazy hypotensive, but are fine on reasonable doses of vasopressors. in general these pts are markedly less sick and do well post-icu

  Scott Weingart
10:13
[Comment From PeterPeter: ] 

In a patient that can’t lie flat for intubation….what steps are you taking to intubate them?

Monday October 13, 2014 10:13 Peter
 
Scott Weingart: 

with VL, you can just tube them sitting up. DSI if they won’t accept preox. you can always lie them down once the induction and relaxant are in

  Scott Weingart
10:13
[Comment From MattMatt: ] 

Would you ever work in a community setting? Or only in academics?

Monday October 13, 2014 10:13 Matt
 
Scott Weingart: 

can’t imagine it. whole purpose of my work is a teaching lab to improve care

  Scott Weingart
10:13
[Comment From JohnJohn: ] 

One more question about jobs… substrate or mentorship?

Monday October 13, 2014 10:13 John
 
Scott Weingart: 

substrate? please define terms

  Scott Weingart
10:14
Adaira Landry: 

Only 15 more minutes of questions with Dr. Weingart! Get them in before we close off the night!!

Monday October 13, 2014 10:14 Adaira Landry
10:15
[Comment From Alex KoyfmanAlex Koyfman: ] 

discuss a pt or 2 that still haunts you to this day 2/2 you could’ve managed the case better?

Monday October 13, 2014 10:15 Alex Koyfman
 
Scott Weingart: 

as a crit care fellow, the track i placed caused the pt to have a trach-innominate fistula and become brain dead just as he was going to be discharged. we are hard on our surgeons, but they have to live through this stuff all the time. that patient still haunts me. if not for me, he may have gone home to his family

  Scott Weingart
10:15
[Comment From GuestGuest: ] 

How do you manage work and life? Any secrets to success?

Monday October 13, 2014 10:15 Guest
 
Scott Weingart: 

wrong person to ask, haven’t found balance. see path to insanity lecture

  Scott Weingart
10:17
[Comment From Alex KoyfmanAlex Koyfman: ] 

Has your approach to subarachnoid hemorrhage changed at all in the past few years?

Monday October 13, 2014 10:17 Alex Koyfman
 
Scott Weingart: 

Triple H seems to have waned. We have found that the best solution to ICP may be to push CPP higher than 60 and see how the pt responds. Individualized goals. Switched to 23.4% hypertonic, and started using NaBicarb instead of NaCl for the lower % administration

  Scott Weingart
10:17
[Comment From EMFoamerEMFoamer: ] 

how are you going to use tamiflu this season?

Monday October 13, 2014 10:17 EMFoamer
 
Scott Weingart: 

not going to unless forced, it is bullshit

  Scott Weingart
10:17
[Comment From JohnJohn: ] 

another question…Have you ever given a 1x dose of Vanc for say cellulitis and discharged a patient?

Monday October 13, 2014 10:17 John
 
Scott Weingart: 

i don’t discharge in my gig

  Scott Weingart
10:18
[Comment From JohnJohn: ] 

Academic jobs – substrate (have the clinical stuff you are interested in set up) vs. mentorship (great senior faculty, but not currently set up to do what you want to do clinically)

Monday October 13, 2014 10:18 John
 
Scott Weingart: 

gotcha. first job for three years is not a bad way to go if you have a family situation that will allow a move. so go mentorship and then the substrate. more shops you see, the better you are (have failed in this regard, myself)

  Scott Weingart
10:19
[Comment From SammySammy: ] 

what is the perfect length of a core content lecture? should there be any lectures that are > 30 minutes?

Monday October 13, 2014 10:19 Sammy
 
Scott Weingart: 

a master lecturer can do 2 hours easy. 20 minutes is better for most. secret to the masters is they would give 6 twenty minute lectures if you gave them the 2 hours and then stitch them together with transitions that make them seamless

  Scott Weingart
10:22
[Comment From Justin HensleyJustin Hensley: ] 

I recently moved to a place that makes me feel like I went back in time 20 years from what we were doing in residency. How do you approach changing the culture of an entire hospital or city?

Monday October 13, 2014 10:22 Justin Hensley
 
Scott Weingart: 

Wow, that is tough. I think the tact of, “Gee I just came across this article saying…” and sending that to your co-attendings or other departments and asking, “Maybe we can try this for a few months and see how it works.” may be one way to go.

Or you can go the fight inducing route of doing what you think best and then challenging anyone who disagrees to produce evidence to the contrary. be aware people will be praying for you to fuck up if you go this route

  Scott Weingart
10:22
[Comment From MattMatt: ] 

If I’m trying to bring ECMO to my shop how to I sell it to admin?

Monday October 13, 2014 10:22 Matt
 
Scott Weingart: 

2 new trials just published ahead of print in resus: Cheer and Japanese OOHCA trials. for more we talk about it all on edecmo.org

  Scott Weingart
10:23
[Comment From EMFoamerEMFoamer: ] 

f/u question…how do you protect yourself re: what you say on the internet…

Monday October 13, 2014 10:23 EMFoamer
 
Scott Weingart: 

imaginary hospital. no unaltered pt data ever. be able to back up everything you say with evidence

  Scott Weingart
10:24
[Comment From JohnJohn: ] 

Dammit, I know you’re right. Thanks.

Monday October 13, 2014 10:24 John
10:25
[Comment From Alex KoyfmanAlex Koyfman: ] 

do you think ketamine will replace etomidate for induction and roc replace succ for paralysis?

Monday October 13, 2014 10:25 Alex Koyfman
 
Scott Weingart: 

etomidate’s role remains the one that can be taken out before the pt arrives, other than that no benefit.
i like keeping suc and roc around, use the latter 9/10 times

  Scott Weingart
10:27
[Comment From NealNeal: ] 

Have you heard of the FRONTIER trial with NA-1 starting in the new year here in Canada? thoughts? http://www.emergencymedicin…

Monday October 13, 2014 10:27 Neal
 
Scott Weingart: 

nope, just looked–super interesting

  Scott Weingart
10:29
[Comment From DaveDave: ] 

3 up and coming young EM docs to watch out for???

Monday October 13, 2014 10:29 Dave
 
Scott Weingart: 

Mike Lauria, ex-pararescue still in med school. Entire resident contingent of SMACC. Met John Greenwood and Jim Lantry while they were doing EMCC fellowship they will be superstars

  Scott Weingart
10:30
[Comment From GeorgeGeorge: ] 

how high do you go on fentanyl drop after intubation before adding second third agent to appropriate patient sedation?

Monday October 13, 2014 10:30 George
 
Scott Weingart: 

no limit. pharmacy may impose 250 mcg/hr limit. if you were bolusing with each dose increase, you’ll rarely hit anywhere near this. consider supplemental ketamine

  Scott Weingart
10:30
[Comment From Alex KoyfmanAlex Koyfman: ] 

what’s the best way to discuss cases in which we could’ve done better?

Monday October 13, 2014 10:30 Alex Koyfman
 
Scott Weingart: 

with colleagues you trust–like Cliff Reid for me

  Scott Weingart
10:31
[Comment From HH: ] 

If you had the chance to get a “free” lecture on any topic at all, what would it be?

Monday October 13, 2014 10:31 H
 
Scott Weingart: 

i want Todd Rasmussen to give me a REBOA lecture.

  Scott Weingart
10:31
[Comment From Justin HensleyJustin Hensley: ] 

How successful are you in teaching new learners to commit acts of commission vs those of omission?

Monday October 13, 2014 10:31 Justin Hensley
 
Scott Weingart: 

ask my residents, but i think pretty well

  Scott Weingart
10:33
[Comment From clintclint: ] 

Top 3 cognitive errors in the ed?

Monday October 13, 2014 10:33 clint
 
Scott Weingart: 

i’ll just say one for the rest read Croskerry. We have no perception of how much time goes by while we dick around during a resus. I think you could save many lives if you just had a hired hand who would come up to you and say doc, “That hypotensive pt has now been here 30 minutes,” and “45 minutes” “60 minutes” you get the point. try it during a critical trauma. just announce to the team, this pt has been in the bay 30 minutes what is our plan to move?

  Scott Weingart
10:33
[Comment From HH: ] 

Flip the question: If YOU had the chance to lecture on any topic, what would it be?

Monday October 13, 2014 10:33 H
 
Scott Weingart: 

umm, I have this podcast called EMCrit

  Scott Weingart
10:35
[Comment From Alex KoyfmanAlex Koyfman: ] 

Thx for your time and insight; we should do it again

Monday October 13, 2014 10:35 Alex Koyfman
10:35
Adaira Landry: 

Thanks again everybody for checking out this AMA with Dr. Scott Weingart! Be sure to follow him on Twitter @emcrit and check out his latest on EMCrit.org. Thanks Dr. Weingart for your amazing answers!

Monday October 13, 2014 10:35 Adaira Landry
 
 

Which Pacemaker/ICD is that Again

pacer

I dread calling cardiology to interrogate a pacemaker when the pt is without their wallet card and has nary a clue as to the device type/manufacturer.

Now there is a solution courtesy of the EM REMS blog:

 

Jacob S et al.  Cardiac Rhythm Device Identification Algorithm Using X-Rays: CaRDIA-X.  Heart Rhythm 2011; 8(6): 915-922.

 

Christopher Watford adds:

A good follow-on to that article would be Agullera et al’s “Radiography of Cardiac Conduction Devices: A Comprehensive Review” (Chest and Cardiac Imaging, 2011, doi:10.1148/rg.316115529). I believe LITFL’s R&R put me onto it. Covers recognition of basic pacemaker/ICD types on X-Rays, along with lead types, determining if leads are connected/fractured, etc.

Table-of-Contents and FOAMcc in One Bolus

follow-path

MattGreerMatt Greer placed a comment on my Path to Insanity Post:

I’m currently in my 3rd year of EM residency in California, and hoping to do a Critical Care fellowship in the future. I’ve drank the kool-aid and have tried to read at least the TOC from all these journals for the last few months and I love it!! Its like trying to drink from a fire-hose, but it’s really rewarding when an article that you happen to pick out of the massive flood of articles gets picked up and talked about on the various FOAM sites. The repetitiveness of the important things causes the info to really stick.

I’m a huge nerd and have created a feedly list which includes the TOC of all of your journals as well as a majority of the major EM / CC FOAM sites (in different sections of course). I have shared the opml file with my peers in residency and those that are into the FOAM stuff love it (it saves them from populating their feedly list from scratch). I figured I’d make it available to your readers .

Click Here and Find the Download Link at the Top of the Screen to get the OPML File on to your Computer

download image

 

Then you need to import the file into your RSS Reader (we all recommend Feedly)

 

feedly-opml-import

To get the OPML file imported into feedly:

  1. Click the add content link
  2. Click the OPML icon

You can then remove feeds as you like, but it’ll start you off with a framework.

 

Thanks Matt!

Ebola Diagnosis and Treatment

ebloa-algo

Intensive Care Medicine Worth Knowing has a great post on how to manage Ebola–Just in case, you know…

Expert Commentary on EMCrit

from ALIEM

from ALIEM

A few months ago, my friend Michelle Lin instituted a few new features on the Academic Life in EM Blog (ALIEM). She and her crew of awesome editors added pre-publication critique as well as post-publication, expert peer review. I have debated on numerous occasions in the FOAMosphere all the reasons I find pre-publication peer review to be an unnecessary vestige of a flawed publishing paradigm. Smarter folks than me have said the same thing. On often-visited sites like EMCrit, post-publication peer review happens automatically and with a width and breadth that traditional journals can’t hope for (I love you commenters!).

But there are a few interviews I do for the podcast in which I am a well-informed user, but not an expert. For these ‘casts I am interviewing an expert, but I am giving you just that single practitioner’s viewpoint. It would be nice to balance these podcasts with a separate expert’s take. For these situations, I am taking a page from Michelle’s book. Next Monday, I will have a podcast on PE teams with Oren Friedman. I reached out expert-commentto Jeff Kline to provide expert commentary on this podcast and he was kind enough to oblige. I personally don’t consider this to be peer review and I am staying away from the term entirely. Instead, look for the “expert commentary” symbol on select future podcasts.

Are you Following Jeff Kline’s Twitter Account

klinelab

If you care about pulmonary embolism (PE) and you are not following @klinelab, then you are missing out.

Here are some of the things I have learned so far:

Diagnosis

  • Causes of False Negative D-Dimer: Symptoms>72 hrs, distal clots, lipemia with turbidimetric assays, and blocking proteins
  • Sudden onset of dyspnea or chest pain has zero predictive value for or against PE (Ann Emerg Med 2010;55:307)
  • Two point DVT may not be enough due to missed SFV Clots (J Thromb Thromb 2014;37(3):298)
  • Age <65, witnessed arrest and PEA as initial rhythm predicts >50% probability of PE as the cause of arrest in a small study (see Mike’s comments below) (PMID 15797276)

Evaluation of PE Patients

  • Thrombophilia testing is a waste of time (PMID 23235639)
  • The Daniel EKG Score can rule-in Severe Pulmonary Artery Hypertension (Chest 2001;120(2):474)
  • He uses Hestia to determine acceptably low risk for Out-Pt treatment, but not ones with pulmonary infarction (they bounce back secondary to pain)
  • A study shows high rates of Chronic ThromboEmbolic Pulmonary Hypertension in higher-risk PEs (Thromb Res 2011;127(4):303)

Treatment

  • Patients with metabolic syndrome may have resistance to fibrinolysis with tPA

MedMal

  • Any new onset hypoxemia must be explained clinically and in the chart
  • Must also explain signs of acute pulmonary hypertension on ecg (PMID 19766353)
  • Bronchitis doesn’t cause SOB unless there is bronchospasm

PEMED’s Resus Kit

SNAG-0006

andy-sloasRemember we did an episode with Keith Conover on creating resus resource packs for your body, car, and home? Well, Andrew Sloas of the PEMED podcast took the advice to heart. He created 3 identical kits, for his and his wife’s car and for his house. Crazy or Brilliant? Let us know in the comments section. Here’s Andrew:

PEMED’s Resus Kit

This list is designed to allow you to create a similar emergency resus kit, but saves you the painstaking hours that I spent considering not only how to get all this stuff into a trauma bag, but how to arrange it in the most functional manner.

Click Here for the Full Kit Contents and Where to Buy the Gear

The first column describes the item type and the second column the location of each item. I have also provided you with the merchant i used and a hyperlink to each item’s web-POS page. The price I paid is in the next column, but that will fluctuate. Some of the items must be purchased in bulk, but I try to only have 1-2 in my bag. As you can imagine, the bag is fairly heavy with one of each item. How often are you expecting to get two emergency out of hospital intubations on your family at the same time? Just stick with one item for most things.

Backpack

Compartment-1

Compartment-1-Unpacked

Compartment-1-Unpacked

Compartment 1 – The Main Compartment: This is where all the airway stuff is located (with the exception of the surgical airway kit). When things are really bad (let’s face it they’re really really bad if you ever have to use this kit) and you haven’t looked at the kit in over a year, you wont’ have to relearn where everything is located. Everything you need to intubate is in one space.

Compartment-2

Compartment-2

Compartment 2 – Fluids, Drugs, & Accessories: This section is color coded via the handy multicolor velcro packets that come with the trauma backpack. I labeled each packet with permanent ink to make it easy to find things during a code. Again, the last thing I want to do when I’m thinking about intubating a friend or family member is stop and search for things.

Compartment-3

Compartment-3

Compartment 3 - Central Line, gloves and face shields.

Side-Pockets

Side-Pockets

Side Pockets – For all the non-medical stuff or anything you can’t fit in the main compartments.

 

Kit tips:

  • Some of the items don’t have a merchant listed. Those items were obtained over years of teaching airway. Often your hospital will get rid of items, which would make a great addition to your bag, just because past their expiration date. Make friends with your supply tech.
  • Volume ordered = if I had to buy it in bulk it that is the minimum number you can buy for that price.
  • I keep a central line kit in the bag not because I’m planning on lining-up someone at Arby’s, but because it can be used for so many other things: the scalpel is great for procedures if the other scalpel is in use, the needle is great for thoracostomy, retrograde intubation, or cric.
  • A 10F peds stylet works with a 4.0ET and all adult ETs, so you don’t really need an adult ET stylet.
  • The M6 oxygen tank has a built in wrench, but it’s flimsy and the having an additional oxygen wrench is a necessary backup. Tape the wrench to your oxygen tank or you’ll never find it when you need it.
  • I have a simple CPR resus mask easily accessible in one of the side-pockets because my nanny can’t intubate, but she can use the mask
  • I chose ET sizes 4,5,6, 7 to make sure I have a tube for everyone. I omitted an 8 because I’m not planning on bronching anyone in the field. You could probably get buy with a just a 4, 5, and 6.
  • Super Glue = poor man’s Dermabond. Good for everything from gluing in an IV or chest tube, to repairing small lacerations. This is the item in my bag that I use the most…for lacerations, not chest tubes.
  • I only have an adult EpiPen (no EpiPen Jr in the bag), why no peds dosing, because an overdose of epi doesn’t make your head, heart, or lungs explode. 300-500 mcg ain’t going to hurt anyone (even a child). If they need epi they need epi so just give he adult dose….
  • Cric Kit, just bc I happen to have one and I like contingency plans, but for me I perform surgical airways with a bougie and scalpel.
  • Suction Tubing: Great tubing for Heimlich valve – thoracostomy tube also a good 2nd tourniquet
  • Why an 8F Thoracostomy tube: it has a needle-like trochar stylet, which makes it the most perfect device invented for needling a tension PTX in the field when there are no other options. Put it in the same place you’d put a chest tube; even with the nipple. Once your in, just slip the tube in over the trochar-stylet. I prefer the traditional surgical technique (no trochar) when in a controlled environment like the ED.
  • Write instructions on things you don’t use all the time (ie. “Blue goes toward the chest”on the Heimlich valve package).

 

 

Handwashing – Shakes and Bumps

fist-bump

Having just returned from SMACC, I’ve been thinking of all of the wonderful people with whom I got to interact. Always a delight is the inestimable Vic Brazil. I remember her gently mocking the EMCrit site for its absence of a single article on handwashing. While this is merely tangential, a search of the site for “handwashing” will now bring up this post saving me from any further shame:

 

Reducing pathogen transmission in a hospital setting. Handshake verses fist bump: a pilot study

Ghareeb PA1, Bourlai T, Dutton W, McClellan WT.

J Hosp Infect. 2013 Dec;85(4):321-3. doi: 10.1016/j.jhin.2013.08.010.

Abstract

Handshaking is a known vector for bacterial transmission between individuals. Handwashing has become a major initiative throughout healthcare systems to reduce transmission rates, but as many as 80% of individuals retain some disease-causing bacteria after washing. The fist bump is an alternative to the handshake that has become popular. We have determined that implementing the fist bump in the healthcare setting may further reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake.

PMID: 24144553 [PubMed – in process]

Update:

Has it always struck you as silly to mandate hand-washing prior to putting on gloves for simple exams? Well, your intuition is quite correct it seems:

Am J Infect Control. 2013 Nov;41(11):994-6. doi: 10.1016/j.ajic.2013.04.007. Epub 2013 Jul 24.

Editorial

Here is a viewpoint on handshakes in the healthcare setting

Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time?–a randomized controlled trial.

Abstract

BACKGROUND:

Hand hygiene (HH) is recognized as a basic effective measure in prevention of nosocomial infections. However, the importance of HH before donning nonsterile gloves is unknown, and few published studies address this issue. Despite the lack of evidence, the World Health Organization and other leading bodies recommend this practice. The aim of this study was to assess the utility of HH before donning nonsterile gloves prior to patient contact.

METHODS:

A prospective, randomized, controlled trial of health care workers entering Contact Isolation rooms in intensive care units was performed. Baseline finger and palm prints were made from dominant hands onto agar plates. Health care workers were then randomized to directly don nonsterile gloves or perform HH and then don nonsterile gloves. Postgloving finger and palm prints were then made from the gloved hands. Plates were incubated and colony-forming units (CFU) of bacteria were counted.

RESULTS:

Total bacterial colony counts of gloved hands did not differ between the 2 groups (6.9 vs 8.1 CFU, respectively, P = .52). Staphylococcus aureus was identified from gloves (once in “hand hygiene prior to gloving” group, twice in “direct gloving” group). All other organisms were expected commensal flora.

CONCLUSION:

HH before donning nonsterile gloves does not decrease already low bacterial counts on gloves. The utility of HH before donning nonsterile gloves may be unnecessary.

Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

KEYWORDS:

Alcohol hand rub; Handwashing; Health care-associated infection; Infection control; Nosocomial infection

PMID: 23891455

EMCrit / ISMMS Conference 2014

handout-2014

Conference Recap

The EMDOCS.net site did a fantastic recap of the conference thereby saving me the trouble.

Live-Tweeting from the Conference


The Talks

The lectures will be posted on the EMCrit site in the coming weeks.

Proper Vancomycin Dosing

VancoBag

Bryan Hayes has a great post on ALIEM on proper dosing of vancomycin.

We are very bad at this in the ED

Proper Vancomycin Dosing

  • 15-20 mg/kg every 8-12 hours in patients with normal renal function [1]
  • In seriously ill patients (eg, sepsis, meningitis, infective endocarditis) with suspected MRSA infection, a loading dose of 25-30 mg/kg may be considered [3]
  • Actual body weight should be used
  • IDSA recommends a max dose of 2 gm
  • In adults, we round to the nearest 250 mg increment

See the post for more and all of the references