The Columbo Tactic: Bridging Generational Learning in Bedside Teaching

27 Aug
August 27, 2015

The Columbo Tactic“I’m not sure what’s going on with this patient,” MS-3 Samir says, as he concludes his disorganized presentation to his attending, Dr. Gonzales. Dr. Gonzales listens and astutely picks up on the needle diagnosis in the haystack of his cacophony. At this point, Dr. Gonzales has two choices:

  1. She can authoritatively correct Samir, give him the answer, and tell him how he just didn’t cut it, or
  2. She can nurture scientific inquiry and lead him to process towards the correct diagnosis with some educational tactics.

“So let me get this straight,” she replies. “You’ve got a person with fever, anorexia and migratory abdominal pain that ends up in the right lower quadrant… Hmmmm. I think this sounds like something important, but I’m just not able to put my finger on it. What do you think?” she responds. Samir ponders, then retorts, “appendicitis?” “Oh yes, that might be what’s going on here; good call!” replies Dr. Gonzalez.   What did Dr. Gonzales do? She successfully utilized the Columbo Tactic. So, what is the Columbo Tactic, and why should you consider implementing this clinical teaching approach? Read more →

Presentation Zen

24 Aug
August 24, 2015

Presentation ZenRecently, I just finished reading a book called Presentation Zen by Garr Reynolds.  This book is a game changer in the presentation world in my humble opinion.  If you are giving presentations at any level, this is a must read book.  Now I know that REBEL EM has traditionally been a clinical blog, but every once in a while we come across something that is just too good to not share. What I am going to try and do in this blog post is summarize some of the key messages of this book.  In the book the author basically breaks presentations down into 3 parts and applies principles from the art of Zen:

  • Restraint in Preparation
  • Simplicity in Design
  • Naturalness in Delivery

Read more →

Beyond ACLS – POCUS in Cardiac Arrest

20 Aug
August 20, 2015

Beyond ACLS - POCUS in Cardiac ArrestAs we have discussed in previous posts, the care of patients with cardiac arrest is a key skill for Emergency Providers. ACLS provides a foundation for care but is rife with shortcomings including, but not limited to, reliance on outdated data and inability to adapt in the face of improved understanding of cardiac arrest pathophysiology. The incorporation of technological advances and skills is another massive limitation of ACLS. One of these technologies is point of care ultrasound (POCUS).

Over the last two decades, POCUS has become a integral part of Emergency Medicine training and practice. POCUS allows for rapid, bedside diagnosis of a number of conditions including cholecystitis, urinary retention and ectopic pregnancy. Additionally, it is becoming a greater component in the management of the critical patient where it can be used to assess cardiac contractility, wall motion abnormalities, intraperitoneal free fluid and more. Application of POCUS in all patients with cardiac arrest is simply the next step. This diagnostic modality is not highlighted in the current iteration of ACLS but is a practice changer. The bottom line is that application of POCUS in cardiac arrest allows the emergency provider to guide resuscitation with a direct look into the body – we are no longer blind.

For this post, I want to discuss two ways that we can use ultrasound in cardiac arrest patients, specifically in pulseless electrical activity (PEA), in the Emergency Department:

  1. Assessment for the presence or absence of cardiac output and
  2. As an alternate framework to the Hs and Ts.

A quick disclaimer – I am not an ultrasound expert, I did not do a fellowship but I am passionate about it’s application in our sickest patients. Read more →

August 2015 REBELCast

17 Aug
August 17, 2015

August 2015 REBELCastWelcome to the August 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics. First topic: renal colic. Renal colic is a commonly seen condition encountered in emergency departments and the use of medical expulsive therapy (MET) is commonly recommended by our urology colleagues. Proponents of MET in the treatment of ureteric colic advocate for them due to their potential ability to increase stone passage, reduce pain medication use, and reduce urologic interventions. Second topic: pediatric weights. In pediatric resuscitations many of use the Broselow tape to predict weights for dosing of medications.  With the increasing weights in pediatric patients seen in developed countries around the world, does the commonly used Broselow tape accurately predict weights?   So with that introduction today we are going to specifically tackle:

Topic #1: MET for Renal Colic
Topic #2: Use of the Broselow Tape to Estimate Pediatric Weights Read more →

Management of Mild to Moderate Asthma Exacerbations

12 Aug
August 12, 2015

Mild to Moderate AsthmaThis post is meant to accompany the REBEL Cast episode on The Crashing Asthmatic from June 2015. This blog post will also be simultaneously posted on the Core EM site here. Come over and check out our core content offerings. Thanks to the REBEL team for continuing to promote our site!

Definition: An episode of wheezing, chest tightness or coughing resulting from variable airflow obstruction that is reversible. Underlying exacerbations are a chronic inflammatory disorder of the airways. Read more →

Post Intubation Sedation for Pregnant Patients

10 Aug
August 10, 2015

Post Intubation Sedation in Pregnant Patients

You have just intubated a seizing eclamptic woman who is 34 weeks pregnant. As she is being prepped for transfer to the OB unit for an emergent C-section your nurse asks you what medications you would like for post intubation analgesia and sedation.

You have limited recollection of whether Propofol crosses the placenta, and have legitimate concerns about Fentanyl’s chances of producing a ‘floppy baby’ for the OB team on delivery.

The literature on the most appropriate post intubation analgesia / sedation package for late pregnancy patients is limited. The agents we are the most familiar with in the emergency department for post intubation sedation and analgesia are Fentanyl and Propofol. One reliable mantra for post intubation analgesia and sedation is ‘Fentanyl is the sauce, and Propofol is the oregano’, it would be great to be able to apply this mantra to the pregnant population also.

Read more →

Medical Expulsion Therapy in Ureteral Colic: An Update

06 Aug
August 6, 2015

Medical Expulsion Therapy 2Back in August 2014, we posted an in depth review on medical expulsion therapy (MET) with tamsulosin in patients with renal colic. The summary of that post was:

“Clearly, there is disagreement in the literature. None of the studies are ideal. We continue to lack a large, RDCT done on patients presenting to the Emergency Department with renal colic.

The best evidence we have DOES NOT show a significant benefit to the use of tamsulosin in renal colic.”

Since that post, two well done RDCTs were published so we thought a brief review of each of these articles and updated recommendations were warranted. Read more →

REBEL Cast Wee: Early Cardiac Catheterization in OHCA Survivors with Non-STEMI

03 Aug
August 3, 2015

Early Cardiac Catheterization in OHCA Survivors with Non-STEMIBackground: We know that cardiac arrest is a devastating disease and that it occurs in approximately 400,000 Americans each year. In the few patients who achieve return of spontaneous circulation (ROSC) and survive past the pre-hospital stage, mortality rates range from 50 – 60% depending on which sources you read. Neurologic injury is the primary reason for mortality in cardiac arrest patients who do survive to hospital admission and while therapeutic hypothermia (TH) is now an established and recommended therapy to help improve survival and neurologic outcomes in cardiac arrest survivors, the mortality rate is still high in this population.   Acute coronary syndrome (ACS) accounts for the majority of cases of cardiac arrest in adults and some recent studies have shown that early cardiac catheterization (CC) and immediate percutaneous coronary intervention (PCI) are associated with improved survival following cardiac arrest. However, many of the patients included in these studies had ST-elevation myocardial infarction (STEMI). There is already a Class 1 recommendation for early CC & PCI in the setting of STEMI following cardiac arrest, but the data on early CC in comatose post-arrest patients without STEMI is very limited. Post-resuscitation electrocardiogram (ECG) is often unreliable and lack of ST-elevation has a poor sensitivity for the diagnosis of acute coronary occlusion. Recently the American College of Cardiology/American Heart Association (ACC/AHA) proposed and published a new consensus statement an algorithm to stratify cardiac arrest patients who are comatose for CC activation. As part of this algorithm non-ST elevation myocardial infarction (NSTEMI) was added as an indication for CC activation. So with that introduction today on REBEL Cast we are going to specifically tackle:

  • Topic: Early Cardiac Catheterization in OHCA Survivors with Non-STEMI

Read more →

Critical Care Horizons – A FOAM Critical Care Journal

30 Jul
July 30, 2015

Critical Care HorizonsAs the world of Free Open Access Medical Education has expanded over the last 5 years, one area that has been a laggard is the traditional journal. Although some journals release a limited number of articles in an open access format (NEJM, Annals of EM, Academic EM, EM Australasia, etc.) we haven’t seen a true open-access journal that is free to publish and free to read. This changed on June 24th, 2015 when the first issue of Critical Care Horizons was released. Read more →

The Challenge of Fever in Kids

27 Jul
July 27, 2015

FeverFEVER shows up beside the name of a new 3 year old that has just been checked into your department. This can be accompanied by many feelings when you see it from “Why are they here ?” to “I hope the child is not dying.” This is a reasonable range of thoughts depending on your level of experience and resources. Many variables are important with this “chief complaint” from how the temperature was actually obtained, to immunization status of the child, to how does the child look, and many more. In my estimation, fever gets a bad rap from general society. It’s our job to set the tone and fight “fever-phobia” when needed. Let’s examine some aspects of pediatric fever to change your mindset from apprehension, to “I’ve got this”. Read more →

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