Dancing with the Devil: Taking Dabigatran to the OR

Dabigatran 2So you are minding your own business working in the ED at Big Hospital, when two dudes (paramedics) bring in a patient with abdominal pain. As luck would have it, this person has a perforated bowel and needs surgery pretty quickly. AND they are on, yes you guessed it… Wait for it… Dabigatran! You consult your local surgeon and she scratches her scrub cap. “I may not want to take that person to surgery? Let me check with my resources and get back…”

If you are like me, you are seeing more and more patients on Dabigatran. This drug is touted to be superior to traditional warfarin for reduction of stroke in atrial fibrillation patients (Ruff 2014) and has had a lot of momentum by many other studies. Continue reading

The Columbo Tactic: Bridging Generational Learning in Bedside Teaching

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? Continue reading

Presentation Zen

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

Continue reading

Beyond ACLS – POCUS in Cardiac Arrest

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. Continue reading

August 2015 REBELCast

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 Continue reading