What is the Best Anatomic Location for Needle Thoracostomy?
Background: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2nd intercostal space (ICS2) in the mid clavicular line (MCL). With the growth of size in our population worldwide, there has been increasing evidence about two things:
- A 5cm angiocatheter may not be long enough to reach the pleural space
- The 2nd intercostal space at the mid clavicular line (ICS2-MCL) may not be the ideal location for needle decompression
When on shift in the ED we spend more time with a phone in our hand than a laryngoscope. Despite this, we spend a lot more time finessing our laryngoscopy skills than the way we call our consults. Calling an efficient and effective consult / admit can greatly improve our on-shift flow, and therefore happiness. The rest of this post will focus on the art of how to call a consult. 
Lead aVR is a commonly ignored lead and I have even heard of it referred to as the Rodney Dangerfield of ECG leads as it gets no respect. I have anecdotally heard many EM physicians activate the cath lab for STE in lead aVR and many cardiologists say that these are not STEMI patients. So is lead aVR now getting too much respect? Well, I thought it would be a great idea to bring the great Amal Mattu on to the show to answer a few questions for us regarding STE in lead aVR.
Background: It is well documented that the number of visits to the ED for abscesses is on the rise in the US, with methicillin-resistant Staphylococcus aureus (MRSA) being the most common cause of purulent skin and soft-tissue infections. The primary treatment for cutaneous abscesses is incision and drainage (I&D). The prescription of antibiotics after this procedure is not straightforward. On one hand there is increased cost and possibly increased side effects, but on the other hand maybe antibiotics will increase eradication and improve treatment. What is known is that I&D alone will result in resolution in >80% of cases. So this begs the question, should we be empirically prescribing Trimethoprim-Sulfamethoxazole for uncomplicated skin abscesses after I&D? 
We are getting closer to the end of the year and pretty soon 3rd year residents will be graduating and moving on to their first jobs as attending physicians. My own residents have been asking for advice, and I thought this would be a great opportunity to ask some EM educators what their advice would be. Essentially, I asked each of them two basic questions and let them steal the show. For our inaugural first episode I asked Anand Swaminathan if he could give us some of his words of wisdom. 
