May 14, 2019


Essentials of Emergency Medicine 2019 is taking place at the Cosmopolitan Hotel/Casino in Las Vegas, NV. I was asked to give five lectures on varying topics and wanted to share what I discussed at each of these sessions.  If you haven't been to Essentials of Emergency Medicine, you need to add this conference to your list of conferences to attend.  The organizers pride themselves in discussing the latest practice-changing research and have meticulously designed content to maximize enjoyment and retention. In my humble opinion this conference is the quintessential medutainment extravaganza that applies learning theory principles, with amazing speakers, to provide you with the latest and greatest for clinical practice.

April 13, 2017

Background: In 2011, we saw 7 million patients in the emergency department (ED) complaining of chest pain. Most of these patients did NOT have an acute coronary syndrome (ACS) or an acute myocardial infarction (AMI). Missing an AMI is one of the biggest fears we have in the ED. By using validated risk scores, we can help decrease the risk of missing AMI and the resultant adverse events. There are multiple scores available for our use. Thrombolysis in Myocardial Infarction (TIMI) predicts risk of adverse outcomes in the next 14 days. Global Registry of Acute Coronary Events (GRACE) predicts outcomes at 6 months. ED specific scores include HEART and Emergency Department Assessment of Chest Pain (EDACS). But, how well do these scores actually perform? Are we missing AMIs by using these clinical risk scores?

February 18, 2016

Chest Pain (CP) is a very common complaint seen in emergency departments around the world.  In the US specifically  anywhere from 8 - 10 million patients present to the ED complaining of CP.  Many use liberal testing strategies to prevent missing acute coronary syndrome (ACS) or other major adverse cardiac events (MACE), but this is not without increase in healthcare cost and false positive testing leading to more downstream testing.  In recent years there have been several diagnostic protocols developed to help determine a portion of these patients as low risk to facilitate early discharge, prevent this over testing, while still having a >99% NPV for MACE at 30 days. Disclaimer: To be clear, this is the way I manage low risk chest pain and certainly there is more than one way, but I think at the current time in the US, this is the best we have.  Also, at the time of this post being written, we DO NOT have high sensitivity troponins in the US.

April 30, 2015

There are approximately 8 to 10 million patients complaining of chest pain coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS. Despite these numbers the American College of Cardiology/American Heart Association (ACC/AHA) recommends that low-risk chest pain patients receive serial cardiac markers followed by some sort of provocative/objective cardiac testing. Using this strategy amongst low-risk chest pain patients unnecessarily uses resources on those least likely to benefit. Low-risk chest pain patients have ACS rates of <2% and provocative/objective cardiac testing is associated with a significant amount of “downstream” testing (i.e. cardiac catheterization) due to false positive tests. To date, the HEART score has been examined in >6000 patients and demonstrated a high NPV for MACE at 6 weeks exceeding 98%, but until now there has been no randomized trial.

March 9, 2015

Welcome to the March 2015 REBEL Cast, where Swami, Matt, and I are going to tackle a couple of topics that come up frequently in clinical practice in the emergency department. Today we are going to specifically tackle:
  • Topic #1: Oseltamivir (Tamiflu) in the Treatment of Influenza
  • Topic #2: Use of the HEART Score in Low Risk Chest Pain Patients