EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Thu, 22 Aug 2019 15:08:31 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.2 https://emcrit.org/feed/podcast/ 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. Scott D. Weingart, MD FCCM clean episodic Scott D. Weingart, MD FCCM spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD FCCM) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit Project http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org EMCrit 254 – Central Line Tips and Tricks with Robby O and Me from EEM 2019 https://emcrit.org/emcrit/emcrit-254-central-line-tips-and-tricks-with-robby-o-and-me-from-eem-2019/ https://emcrit.org/emcrit/emcrit-254-central-line-tips-and-tricks-with-robby-o-and-me-from-eem-2019/#respond Thu, 22 Aug 2019 15:08:31 +0000 https://emcrit.org/?p=466298 Central Line Tips and Tricks

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/emcrit-254-central-line-tips-and-tricks-with-robby-o-and-me-from-eem-2019/feed/ 0 Central Line Tips and Tricks
I always have a great time at the Essentials of Emergency Medicine conference, not just because it is an amazing conference, but because I get to hang out with my buddy, Rob Orman. This year, we did a on-stage demo of central line tips and tricks. Hope you enjoy:
Here's the Vid:


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Scott D. Weingart, MD FCCM clean 15:51 yes
IBCC chapter & cast: Tumor Lysis Syndrome https://emcrit.org/pulmcrit/tumor-lysis-syndrome/ https://emcrit.org/pulmcrit/tumor-lysis-syndrome/#respond Thu, 22 Aug 2019 11:36:31 +0000 https://emcrit.org/?p=466472 Tumor lysis syndrome isn't encountered very often in critical care, but we will see the most extreme extent of this illness.  Within the last decade, rasburicase has been a game-changer here.  Understanding some basic physiology will guide the optimal diagnosis and treatment of tumor lysis syndrome in the post-rasburicase era. The IBCC chapter is located […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Lifeguard Lessons https://emcrit.org/toxhound/lifeguard-lessons/ https://emcrit.org/toxhound/lifeguard-lessons/#comments Mon, 19 Aug 2019 16:04:04 +0000 https://emcrit.org/?p=466424 by Andrew Stolbach Toxicology and swimming pool management are both applied forms of chemistry. My six summers as a lifeguard and pool operator prepared me to be a doctor as well as any class in medical school (I’m looking at you, histology.) I now work in an emergency department and specialize in toxicology. And, while […]

EMCrit Project by Tox & Hound.

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IBCC chapter: Vaping Associated Pulmonary Injury (VAPI) https://emcrit.org/pulmcrit/vaping-associated-pulmonary-injury/ https://emcrit.org/pulmcrit/vaping-associated-pulmonary-injury/#comments Mon, 19 Aug 2019 12:02:17 +0000 https://emcrit.org/?p=466409 There is currently an outbreak of vaping associated pulmonary injury spanning several states, which is under intense investigation by the Centers for Disease Control.  We will certainly be learning more about this in the coming weeks to months. However, for now, how should we manage patients who present in respiratory distress following vaping?  This chapter […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: hypomagnesemia & hypermagnesemia https://emcrit.org/pulmcrit/magnesium/ https://emcrit.org/pulmcrit/magnesium/#respond Thu, 15 Aug 2019 12:17:42 +0000 https://emcrit.org/?p=466322 Magnesium might be the darling ion of critical care.  It has an interesting array of therapeutic applications ranging from asthma to Torsade de Pointes to preeclampsia.  This pair of chapters discusses the evaluation of both hypomagnesemia and hypermagnesemia. IBCC chapter on hypomagnesemia is located here. IBCC chapter on hypermagnesemia is located here. The podcast & comments […]

EMCrit Project by Josh Farkas.

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PulmCrit- Large volume thora: Can we drain ‘em dry? https://emcrit.org/pulmcrit/large-volume-thora/ https://emcrit.org/pulmcrit/large-volume-thora/#comments Mon, 12 Aug 2019 11:42:52 +0000 https://emcrit.org/?p=466236 How much fluid can safely be removed from a pleural effusion during a thoracentesis? Much has been written about this, but solid evidence remains elusive.

EMCrit Project by Josh Farkas.

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EM Nerd-The Case to the Ecological Ambiguity https://emcrit.org/emnerd/em-nerd-the-case-to-the-ecological-ambiguity/ https://emcrit.org/emnerd/em-nerd-the-case-to-the-ecological-ambiguity/#respond Fri, 09 Aug 2019 20:43:05 +0000 https://emcrit.org/?p=466198 With each publication from Maitland et al we are granted a brief glimpse of a greater medical truth. Only our view is obstructed, as we peer through the constricted aperture created by the questions regarding its external validity.  In 2011, Maitland et al published the FEAST trial in the NEJM (1). This landmark trial called […]

EMCrit Project by Rory Spiegel.

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EMCrit 253 – Kovacs Kata to Optimize a Failing Laryngoscopy Attempt https://emcrit.org/emcrit/kovacs-kata/ https://emcrit.org/emcrit/kovacs-kata/#comments Fri, 09 Aug 2019 15:07:49 +0000 https://emcrit.org/?p=466180 dedicated to my friend, George Kovacs

EMCrit Project by Scott Weingart.

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You do perfect patient positioning.

You open the mouth.

A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla.

And you see...

Nothing!

What now?

Abandon the attempt--nope!

Use the Kovacs Kata

The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs.

George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques:
1. Neck
Neck refers to external laryngeal manipulation (ELM).

* Bimanual Laryngoscopy on LitFL
* Levitan Study on BiManual/ELM

2. Head
If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head.

* Kovacs Head Lift Video
* Keith Greenland on Why this Works
* Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy

3. Hands
If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body.
4. Scoop
If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller.

* Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver

5. Pull Back
This one is for the hyperangulated blade. You have a great view--you just can't get the tube to go into the glottis.

* Why too close is too bad
* George on Hyperangulated Problem-Solving
* Levitan on HyperAngulated Blade Use and the Kovacs Sign

Additional Attributions

* Full Kata Video

Now on to the Vodcast...


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Scott D. Weingart, MD FCCM clean 19:56 yes
IBCC chapter & cast – Septic Shock https://emcrit.org/pulmcrit/sepsis/ https://emcrit.org/pulmcrit/sepsis/#comments Thu, 08 Aug 2019 09:54:03 +0000 https://emcrit.org/?p=466161 Septic shock is perhaps the defining illness of medical intensive care.  As such it is an enormously broad and controversial topic.  This chapter attempts to provide a unified and straight-forward approach.  However, every physicians has a different approach to septic shock, so it's impossible to claim that this is the best approach. There will doubtless […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Some Like It HOT https://emcrit.org/toxhound/some-like-it-hot/ https://emcrit.org/toxhound/some-like-it-hot/#comments Mon, 05 Aug 2019 16:28:23 +0000 https://emcrit.org/?p=466086 by Dan Rusyniak Stimulant-Induced Hyperthermia, a (sort of) memoir. I will admit my biases up front. This post is based primarily on my own research or the research of people I have collaborated with. There may be other viewpoints out there, but I will stick with what and who I know. If someone disagrees with […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Angioedema https://emcrit.org/pulmcrit/angioedema/ https://emcrit.org/pulmcrit/angioedema/#comments Thu, 01 Aug 2019 11:46:42 +0000 https://emcrit.org/?p=465993 Like so many things in critical care, angioedema is difficult to research since it is uncommon, heterogeneous, and emergent.  As such, we have relatively little high-quality evidence regarding this disease (and the high-quality evidence that we do have is largely restricted to pharma-sponsored trials of new and insanely expensive pharmaceuticals).  This chapter attempts to create […]

EMCrit Project by Josh Farkas.

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PulmCrit Wee: Reconceptualizing bradykinin-mediated angioedema as a universal vicious spiral https://emcrit.org/pulmcrit/bradykinin-spiral/ https://emcrit.org/pulmcrit/bradykinin-spiral/#comments Wed, 31 Jul 2019 10:53:05 +0000 https://emcrit.org/?p=465951 In 2015 I wrote this post on ACEi-induced angioedema.  I still think it was a pretty good post (particularly for 2015), but it’s become increasingly clear recently that the post was fundamentally flawed.  Let’s try to straighten this out.  old model of bradykinin-mediated angioedema This is a conceptual model of how bradykinin-mediated angioedema occurs.  Several […]

EMCrit Project by Josh Farkas.

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PulmCrit – Early basal insulin in DKA https://emcrit.org/pulmcrit/early-basal-insulin/ https://emcrit.org/pulmcrit/early-basal-insulin/#comments Mon, 29 Jul 2019 11:36:07 +0000 https://emcrit.org/?p=465896 The timing of basal insulin administration in DKA has been controversial for years.  I posted the following poll on twitter recently to get a sense of current opinion on this: So, it seems that the majority of people are using traditional management (wait for the anion gap to close, give basal insulin, then shut off […]

EMCrit Project by Josh Farkas.

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EMCrit Podcast 252 – Care-Oriented Resus vs. People-Oriented Resus https://emcrit.org/emcrit/care-oriented-resus/ https://emcrit.org/emcrit/care-oriented-resus/#comments Sun, 28 Jul 2019 17:56:48 +0000 https://emcrit.org/?p=465882 Are you a people-oriented or care-oriented resus doc?

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/care-oriented-resus/feed/ 19 Are you a people-oriented or care-oriented resus doc?

Today, I present an excerpt from an interview with Andrew Davies, host of the mastering intensive care podcast. The full interview was over an hour long, but this is a polarizing excerpt.
The Full Mastering Intensive Care Interview

* Scott Weingart being interviewed by Andrew Davies

REANIMATE 7 Conference

* reanimateconference.com

Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 20:35
Tox and Hound – Fellow Friday – The Cardiovascular Toxicity of Plant Sodium Channel Openers https://emcrit.org/toxhound/ff-plant-sodium-channel-openers/ https://emcrit.org/toxhound/ff-plant-sodium-channel-openers/#respond Fri, 26 Jul 2019 13:31:41 +0000 https://emcrit.org/?p=463357 When you’re having a bad day, consider the teratogenic effects of the Veratrum alkaloid, cyclopamine. Scientists say that an attempt to understand sodium channel openers, in and of itself, may produce similar effects. The Cardiovascular Toxicity of Plant Sodium Channel Openers Mad Honey, Cyclopic Ruminants, Sneezing Powder, and Herbal Death Grayanotoxins, Veratrum Alkaloids, and Aconitum […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Severe hemoptysis https://emcrit.org/pulmcrit/hemoptysis/ https://emcrit.org/pulmcrit/hemoptysis/#comments Thu, 25 Jul 2019 11:21:05 +0000 https://emcrit.org/?p=465810 Severe hemoptysis is a true challenge.  Due to the rarity of this condition, there is little high-quality data on it.  So you can't become a hemoptysis whisperer by reading books.  Unfortunately, due to the rarity of the condition it's also difficult to accumulate clinical experience. 

EMCrit Project by Josh Farkas.

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The Dantastic Mr. Tox & Howard – S02E11 – Labs Before Lectures https://emcrit.org/toxhound/labs-before-lectures/ https://emcrit.org/toxhound/labs-before-lectures/#comments Mon, 22 Jul 2019 19:35:14 +0000 https://emcrit.org/?p=465639 A decade of toxicologic history with Dr. Howard McKinney, Jr. Join Dan (@drusyniak) &Howard (@heshiegreshie) as they turn on, tune in, and drop out with Dr. Howard McKinney, Jr. during the Summer of Love and the “Decade of Tox”. They’ll remind you to always know your chemist, round up your spotters, chill out in the […]

EMCrit Project by Tox & Hound.

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EMCrit Wee – Semper Vitae – GRM with Helen Perry https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/ https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/#comments Sat, 20 Jul 2019 16:52:15 +0000 https://emcrit.org/?p=462423 There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work. Their motto is semper vitae–always life. Their mission is to provide life saving emergency and prehospital care to those impacted […]

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/emcrit-wee-semper-vitae-grm-with-helen-perry/feed/ 10 There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work. Helen Perry ACNP-BC, MSN, RN, CCRN, CEN Helen Perry ACNP-BC, MSN, RN, CCRN, CEN
Their motto is semper vitae--always life. Their mission is to provide life saving emergency and prehospital care to those impacted by war and conflict.
Find Global Response

* The website is www.global-response.org
* Instagram global.response
* Facebook
* Twitter @GRM_Global

Volunteer
We are always looking for qualified volunteers and we use Paramedics and above. EMTs are welcome to apply, but they may not be working in a clinical capacity due to World Health Organization minimum operating standards. We even need non-medical folks (social media marketing, finance, smart computer people, grant writers, etc.)
Donate
They are a registered not-for-profit (501c3) and their admin budget is super low. Please consider helping these folks.
Note
I have had to close this post to comments b/c there have been a number of comments made by folks with false names and/or false contact information. The policy of this site is that all commenters must use their real identity linked to a real email address. There seems to be a group of folks out there that doubts the veracity of the GRM. If you have verifiable information on that, please get in touch by the contact link above.
Now on to the Wee...






 
 
































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Scott D. Weingart, MD FCCM clean 26:19
IBCC chapter & cast – Hyperthermia & heat stroke https://emcrit.org/pulmcrit/hyperthermia/ https://emcrit.org/pulmcrit/hyperthermia/#comments Sat, 20 Jul 2019 00:54:17 +0000 https://emcrit.org/?p=465669 Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter.  This is a bit of an impromptu post, so we don't have a podcast to go along with it (we will record one eventually – Adam has more experience with the […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Alcohol Withdrawal https://emcrit.org/pulmcrit/etoh/ https://emcrit.org/pulmcrit/etoh/#comments Thu, 18 Jul 2019 11:07:35 +0000 https://emcrit.org/?p=463677 Below is a card from one of the first patients I treated for alcohol withdrawal.  He lingered in the hospital for days on various benzodiazepine regimens (including a lorazepam infusion), and eventually limped home on an oral chlordiazepoxide taper.  He wrote me a thank-you card days after leaving the hospital, but as you can see […]

EMCrit Project by Josh Farkas.

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EMCrit 251 – Philosophical & Psychological Diversions Part II – Naive Reality and the Fundamental Attribution Error https://emcrit.org/emcrit/philosophy-2/ https://emcrit.org/emcrit/philosophy-2/#comments Tue, 16 Jul 2019 17:17:09 +0000 https://emcrit.org/?p=461805 More Philosophical Ramblings...

EMCrit Project by Scott Weingart.

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In Part I of the philosophical diversions series, we discussed free will. Today, let's bring up some other thoughts:
Conscious Decisions
Consciousness by Annaka Harris


Podcast Episode
Naïve Realism
Perception isn't Reality

* Ross, L., & Ward, A. (1996). Naive realism in everyday life: Implications for social conflict and misunderstanding. In T. Brown, E. S. Reed & E. Turiel (Eds.), Values and Knowledge (pp. 103–135).

Fundamental Attribution Error
Synopsis
Umvelt
The RCM is Back in Stock


resuscrisismanual.com
Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 25:28
Tox and Hound – Archery: The Official Sport of Medical Toxicology https://emcrit.org/toxhound/archery/ https://emcrit.org/toxhound/archery/#comments Mon, 15 Jul 2019 20:25:41 +0000 https://emcrit.org/?p=463595 A very special welcome to our newest hound, Dr. Trevonne Thompson! You can learn more about him here . . . by Trevonne Thompson Archery should be recognized as the official sport of medical toxicology. Medical Toxicology is, by my own estimation, an avant-garde specialty, and is arguably the best specialty in medicine. While its modern history, […]

EMCrit Project by Tox & Hound.

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Pulmcrit- Evidence Update: Phenobarbital in Alcohol Withdrawal https://emcrit.org/pulmcrit/phenobarb-sampler/ https://emcrit.org/pulmcrit/phenobarb-sampler/#comments Mon, 15 Jul 2019 11:38:26 +0000 https://emcrit.org/?p=463522 Over the past year, the five papers below were published regarding the use of phenobarbital in alcohol withdrawal. These studies aren’t massive, glittering multicenter RCTs (and, realistically, it’s dubious whether such a study will happen). However, these papers bring some unique and interesting perspectives to the table. This post will summarize them briefly - a bit like a sampler flight of beers (figure above).

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Ascending cholangitis & calculus cholecystitis (community-acquired biliary sepsis) https://emcrit.org/pulmcrit/biliary/ https://emcrit.org/pulmcrit/biliary/#comments Thu, 11 Jul 2019 10:40:42 +0000 https://emcrit.org/?p=463501 Biliary infection is a fairly common cause of septic shock (especially ascending cholangitis).  Evidence isn't terrific regarding exactly when and how interventions should be done to obtain source control (particularly among cholecystitis).  This chapter attempts to reach some clarity on the topic but honestly, it remains a bit murky.  

EMCrit Project by Josh Farkas.

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Tox and Hound – The Physostigma https://emcrit.org/toxhound/physostigma/ https://emcrit.org/toxhound/physostigma/#respond Tue, 09 Jul 2019 16:23:08 +0000 https://emcrit.org/?p=463458 A very special welcome to our newest hound, Dr. Jon Cole! You can learn more about him here . . . by Jon Cole It’s a busy day in the ED. ICU beds are tight, ambulances keep coming, and triage grows at a seemingly exponential rate. Waiting for you are your first three patients, all of whom […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Breastfeeding on Bup https://emcrit.org/toxhound/breastfeeding-bup/ https://emcrit.org/toxhound/breastfeeding-bup/#respond Fri, 05 Jul 2019 17:31:32 +0000 https://emcrit.org/?p=463276 A very special welcome to our newest hound, Dr. Christine Murphy! You can learn more about her here . . . by Christine Murphy Several months ago, I was taking care of an infant whose mother was terrified she would cause opioid withdrawal if she stopped breastfeeding. The mother was on medication assisted therapy (MAT) with buprenorphine, […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Clostridioides Difficile https://emcrit.org/pulmcrit/cdiff/ https://emcrit.org/pulmcrit/cdiff/#comments Thu, 04 Jul 2019 12:08:14 +0000 https://emcrit.org/?p=463258 Clostridioides (previously clostridium) difficile is an inescapable problem within the critical care arena.  This may arise as a nosocomial complication, in which case it is usually diagnosed early and treated successfully.  It may also be the primary cause of admission to the ICU, in which case it is generally more severe.  

EMCrit Project by Josh Farkas.

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Dual External Defibrillation: Close, but Not Touching by Mark Ramzy https://emcrit.org/emcrit/double-defibrillation/ https://emcrit.org/emcrit/double-defibrillation/#comments Wed, 03 Jul 2019 23:08:55 +0000 https://emcrit.org/?p=462818 The scoop on dual defibrillation

EMCrit Project by Guest Author.

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PulmCrit- Rigorous vs. lenient spontaneous breathing trials: The answer at last? https://emcrit.org/pulmcrit/psv8/ https://emcrit.org/pulmcrit/psv8/#comments Mon, 01 Jul 2019 10:43:34 +0000 https://emcrit.org/?p=463110 background There has long been debate about exactly how to design a spontaneous breathing trial.  If the trial is made too easy, then patients would be extubated before being ready (leading to re-intubation).  Alternatively, if the trial is too hard, that would prolong mechanical ventilation beyond the point of being beneficial.  The figure above shows […]

EMCrit Project by Josh Farkas.

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EMCrit Podcast 250 – The OMI Manifesto Lecture by Pendell Meyers https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture-by-pendell-meyers/ https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture-by-pendell-meyers/#comments Thu, 27 Jun 2019 19:15:55 +0000 https://emcrit.org/?p=462594 A video version of the rebellion's attempts to overthrow the STEMI Empire

EMCrit Project by Pendell Meyers.

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Pendell Meyers is attempting to change the paradigm of classifying MIs as STEMI vs. NSTEMI. An important first step in this attempt was his publishing the
OMI Manifesto
However, many folks just don't read, so here is a video version.




Ideas to Think About...

* False Negative Paradox
* Why did the term stemi equivalents not catch on?
* Why is there not currently a retrospective coding of missed occlusive MIs?

Please, please put your thoughts and comments below

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Scott D. Weingart, MD FCCM clean 53:48 yes
IBCC chapter & cast – Fluid selection & pH-guided fluid resuscitation https://emcrit.org/pulmcrit/fluid/ https://emcrit.org/pulmcrit/fluid/#comments Thu, 27 Jun 2019 11:43:32 +0000 https://emcrit.org/?p=463075 Based on this polling data, 42% of you will hate this chapter.  It's a good thing I'm not running for president. Seriously though, fluid selection remains controversial.  This chapter presents an approach which makes sense physiologically and is supported by a substantial amount of animal and human data. 

EMCrit Project by Josh Farkas.

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Tox and Hound – Fear and Loathing in Alcohol Withdrawal https://emcrit.org/toxhound/fear-and-loathing-etoh/ https://emcrit.org/toxhound/fear-and-loathing-etoh/#comments Tue, 25 Jun 2019 19:34:44 +0000 https://emcrit.org/?p=463021 by Jeff Lapoint “I was not proud of what I had learned, but I never doubted that it was worth knowing.” Hunter S. Thompson I don’t know why I’ve been identifying with the works of Hunter S Thompson of late. It’s not because the political times seem eerily similar to that of 1972, nor because […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Hypercalcemia https://emcrit.org/pulmcrit/hypercalcemia/ https://emcrit.org/pulmcrit/hypercalcemia/#respond Thu, 20 Jun 2019 13:27:40 +0000 https://emcrit.org/?p=462906 Hypercalcemia isn't a particularly common cause of critical illness, but when encountered this requires immediate treatment.  Fortunately, advances in the treatment for hypercalemia have clarified how to do this safely and definitively.  Forced diuresis with furosemide has largely fallen by the wayside, simplifying fluid and electrolyte management.  The cornerstone of therapy is generally simultaneous initiation of calcitonin and an IV bisphosphonate.

EMCrit Project by Josh Farkas.

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PulmCrit- TEG for cirrhotic coagulopathy: Time for clinical implementation? https://emcrit.org/pulmcrit/teg-cirrhosis/ https://emcrit.org/pulmcrit/teg-cirrhosis/#comments Mon, 17 Jun 2019 12:22:45 +0000 https://emcrit.org/?p=462693 Introduction Traditional coagulation studies (especially the INR) fail miserably in cirrhosis.  Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients.  This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you're not familiar with this concept already, it's explained […]

EMCrit Project by Josh Farkas.

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The Case of the False Imprisonment https://emcrit.org/emnerd/the-case-of-the-false-imprisonment/ https://emcrit.org/emnerd/the-case-of-the-false-imprisonment/#comments Sat, 15 Jun 2019 00:40:02 +0000 https://emcrit.org/?p=462823 In the FOAM community a great deal of time is spent discussing the appropriate manner of transitioning critically ill patients onto mechanical ventilation. A far larger portion of the practice of critical care is spent determining how best to liberate our patients from the ventilatory shackles with which we have bound them. The specifics of […]

EMCrit Project by Rory Spiegel.

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EMCrit 249 – You Can Either Learn or You Can Blame – Fixing the Morbidity and Mortality Conference with George Douros https://emcrit.org/emcrit/fixing-mm-conf/ https://emcrit.org/emcrit/fixing-mm-conf/#comments Thu, 13 Jun 2019 14:20:59 +0000 http://emcrit.org/?p=451726 How to make your M&M conference important and useful

EMCrit Project by Scott Weingart.

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You Can Either Learn or You Can Blame, You Can't Do Both
--Sydney Dekker
 
Steps Prior to the M&M
Find a Case
The standard referral paths (hospital reporting, pissed off administrators, mortalities) will happen automatically. But you also want to establish yourself as a Master of Whisperers. The way to get people to report cases is to inspire trust. You need to offer protection, establish clear patterns of non-putative motives, and show that you actually do something with the information reported.
Build a Thin Timeline
Comb the chart to build an initial time-line. This will only reflect events, but will offer little actual understanding of what took place.
Interview Primary Decision-Makers

* Dr. Douros asks lets them know he wants to meet over coffee and asks them to write up a 1 paragraph description of events.
* He sends out a Pre-Reading Sheet of what to expect.
* The goal is to find the inflection point where things diverted from optimal care
* Then to get to the point where the actions that occurred make sense
* Seek to Understand Local Rationality

* Knowledge at the time
* Focus at the time
* Goals at the time


* Goals of this interview overlap greatly with the skillset of a simulation debriefer. As such, check out Simulcast for amazing resources.

Build a Thick Timeline
Incorporate the results of the interview(s) into the timeline

Remember, ED cases are not contiguous they are stimulus/response based
Analyze for Systemic Problems and Brainstorm Solutions
Behavior must be judged as if the outcome is not known. If it was ok when things go right, it is ok when things go wrong.

 
Presenting the M&M
Dr. Douros does 2 cases in a one-hour block, 1 of them an M&M and the other a Safety & Success case (similar to the Amazing & Awesome Rounds).
PreBrief
Remind the group that this is about learning and identifying systemic problems, not about blame & shame.
Present the Thin and Thick Timelines

* Should take about 10 minutes.
* Exclude extraneous information
* The case can be presented by a Junior, but there needs to be a master facilitator at all sessions

Discuss the Case
~10-15 minutes
Probe for Systemic Problems and Solutions
~10-15 minutes
Send F/U Email with Lessons
To reinforce for those who attended and fill in those who did not
Recommended Resources


The Field Guide to Understanding 'Human Error'

This is the first go-to, a must read. It will change your vision of error.

Next, you can move on to another Dekker book:

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IBCC chapter & cast: Serotonin syndrome https://emcrit.org/pulmcrit/serotonin/ https://emcrit.org/pulmcrit/serotonin/#respond Thu, 13 Jun 2019 12:11:00 +0000 https://emcrit.org/?p=462777 Serotonin syndromes comes up a lot in critical care medicine.  Sometimes we are admitting patients because of a primary diagnosis of serotonin syndrome.  Other times we are afraid of causing serotonin syndrome ourselves, due to polypharmacy.  In both scenarios, there may be uncertainty regarding whether or not a patient has serotonin syndrome. This chapter explores […]

EMCrit Project by Josh Farkas.

]]> https://emcrit.org/pulmcrit/serotonin/feed/ 0 Tox and Hound – A Few Days on the Drug Circuit https://emcrit.org/toxhound/drug-circuit/ https://emcrit.org/toxhound/drug-circuit/#comments Wed, 12 Jun 2019 02:39:31 +0000 https://emcrit.org/?p=462747 by Jeanna Marraffa A 45-year-old male with history of cardiomyopathy has an out of hospital cardiac arrest. Resuscitative efforts were initiated pre-hospital and return of spontaneous circulation (ROSC) was achieved. However, upon arrival to the emergency department (ED), he was profoundly hypotensive with a blood pressure of 50/palp and a heart rate of 40 beats […]

EMCrit Project by Tox & Hound.

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Tox and Hound – In the Beginning https://emcrit.org/toxhound/in-the-beginning/ https://emcrit.org/toxhound/in-the-beginning/#comments Thu, 06 Jun 2019 14:15:24 +0000 https://emcrit.org/?p=462619 by Diane Calello Risk Assessment in Acetaminophen Toxicity In the beginning God created the heavens and the earth. Darkness covered the formless earth, wind swept over the waters. And God said, “Let there be acetaminophen”. And so it was. And it was good. Then man discovered acetaminophen and, realizing he was naked without it, covered […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast: Tick-borne infections https://emcrit.org/pulmcrit/tick/ https://emcrit.org/pulmcrit/tick/#comments Thu, 06 Jun 2019 12:45:20 +0000 https://emcrit.org/?p=462641 It's spring in Vermont... when a young intensivist's thoughts go from fancy to tick-borne diseases.  Climate shifts are causing an increase in tick-borne illnesses, such that these are now considered emerging infections in many areas (including the northeast United States and Canada).  These diseases can be extremely difficult to diagnose, as they will often present with a nonspecific flu-like illness and may subsequently progress to multi-organ failure.  Misdiagnosis of a tick-borne illness as bacterial septic shock would lead to inadequate treatment, as these diseases require specific antibiotic therapy (usually doxycycline).  This chapter focuses on diagnosis and empiric therapy for these very challenging infections.  

EMCrit Project by Josh Farkas.

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