September 30, 2015

I was recently invited by Rick Body and Natalie May to speak at the Royal College of Emergency Medicine (RCEM) Meeting in Manchester, England, September 2015.  The topic was "The Essence of Emergency Medicine."  I was allotted 20 minutes to give this talk and in my mind I immediately thought about two questions:

  1. How am I supposed to talk about the essence of EM in 20 minutes?
  2. What is it that we really do in the emergency department on a day to day basis?
So instead what I did, was make an executive decision to change the lecture to something slightly different.  I figured we could talk about the modern day superhero.  When you think about it, some of the things we are asked to do in the first 20 minutes of a patients care, truly are superhuman. Now when we were kids, many of us wanted to be superheroes.  How many of us tied a table cloth or towel around our necks like a cape?  Well, to me emergency medicine is one of the closest things to a  modern day superhero.  So instead of the essence of emergency medicine, I gave a talk on the five powers of the modern day superhero.  To me, these are the things that encompass the essence of EM and our initial care of patients.

September 24, 2015

Background: When evaluating therapeutic options for PE, there are three categories in my mind: Subsegmental, Submassive, and Massive. For simplicity sake lets just say subsegmental PEs get treated with anticoagulation and massive PEs get treated with thrombolysis. The submassive category is a bit trickier. For example the PEITHO trial looked at full dose systemic fibrinolysis, tenecteplace in intermediate-risk pulmonary embolism and found a reduced risk of death or cardiovascular collapse by 56% but this was offset by an almost 5-fold increased risk of major bleeding and 10-fold increased risk of intracranial hemorrhage compared to anticoagulation alone. The MOPETT Trial on the other hand, looked at half dose systemic tPA for submassive PE and found that there was a significant reduction in pulmonary artery systolic pressures at 28 months vs usual care, with no increase in intracranial hemorrhage but failed to show any statistical mortality benefit compared to anticoagulation alone. Maybe a more simple answer to the submassive PE group would be to do catheter directed thrombolysis at lower doses than given with systemic fibrinolysis.

September 21, 2015

Background: Some of the major take home points from the sepsis trilogy of studies recently published (ProCESS, ARISE, and ProMISe) was that early identification of patients with sepsis, early intravenous fluids, and timely, appropriate broad-spectrum antibiotics is key to decreasing morbidity and mortality. In 2006 a study by Kumar et al [3] showed a 7.6% increase in mortality in patients with sepsis for every hour of delay after the onset of shock, but this finding has not been reproduced. In fact, the results of timing of antibiotic administration on outcomes have been all over the map. Regardless, the Surviving Sepsis Campaign still has very specific recommendations regarding the timing of antibiotics. And even more painful is that metrics for the quality of care of patients with severe sepsis and septic shock are now recognizing these recommendations as core measures.

September 14, 2015

Background: In patients with cardiovascularly stable supraventricular tachycardia (SVT), the valsalva maneuver is recommended as an initial maneuver to help with cardioversion. The success rate of the valsalva maneuver alone is documented at 5 – 20%. The next option for patients who still remain in SVT is intravenous adenosine. Adenosine briefly stops all conduction through the AV node, which causes patients to feel a sense of doom or like they are about to die. Increasing venous return and vagal stimulation by laying patients supine and elevating their legs may increase the rate of conversion and is simple, safe, and cost effective.

September 10, 2015

“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