Ten (Trauma Resuscitation) Commandments

10 Sep
September 10, 2015

Commandments1“I’ve been in this game for years, it made me an animal
There’s rules to this sh*t; I wrote me a manual”
— Notorious BIG

You know, whether you sling crack rocks or not, there are some sage words of wisdom in the late Notorious BIG’s Ten Crack Commandments. Life pearls like “Never let ‘em know your next move” and “Never keep no weight on you” have helped guide me through some challenging life decisions.

1. Never let no one know how much dough you hold
2. Never let ‘em know your next move
3. Never trust nobody
4. Never get high on your own supply
5. Never sell no crack where you rest at
6. That Goddamn credit, forget it
7. Keep your family and business completely separated
8. Never keep no weight on you
9. If you ain’t getting bags stay the f*ck from police
10. A strong word called consignment; If you ain’t got the clientele say hell no

Table 1. The ten crack commandments.

While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate. From damage control to fibrinogen, from TXA to thromboelastometry, there is no doubt that resuscitating a bleeding trauma patient is a more nuanced endeavor than we originally envisioned it.

So, inspired by Biggie’s Descartesian ten-point discourse on method, I present the ten rules of the contemporary trauma resuscitation game as I see them – backed by science, and occasionally editorialized with personal opinion.

* Some academics have argued that the game has in fact not changed, but has just become more fierce; see Slim Charles vs. Cuddy Read more →

September 2015 REBELCast

07 Sep
September 7, 2015

September 2015 REBELCastWelcome to the September 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Venous Thromboembolism (VTE). Seems like we are hearing more and more about VTE in terms of workup, management, etc. Lets face it, diagnosing someone with a pulmonary embolism (PE) is no longer as simple as checking a d-dimer or just doing a CT Pulmonary Angiogram.  There is so much more to it and to frustrate physicians even more there is so much research coming out on this topic alone, even I am having a hard time keeping up.  Swami, Matt, and I thought it might be good to tackle a couple of articles from he world of VTE that have implications for clinical practice and patient care. So with that introduction today we are going to specifically tackle:

  • Topic #1: Home Treatment of Low Risk Venous Thromboembolism with Rivaroxaban
  • Topic #2: RV Dilation on Bedside Echo Performed by ED Physicians

Read more →

More Dogma: Epinephrine in Digital Nerve Blocks

03 Sep
September 3, 2015

Digital Nerve BlocksYou are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”.

When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content.

The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback) Read more →

Dancing with the Devil: Taking Dabigatran to the OR

31 Aug
August 31, 2015

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. 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 →

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