The White Coat InvestorERCAST add
The White Coat Investor (AKA Jim Dahle, MD) talks debt, investing, philanthropy, investment philosophy, and investment strategies for different stages of your career.
Key Links from this episodeEssentials of Emergency Medicine The White Coat Investor website White Coat Investor book
When Jim was an intern, he didn't know much about finance. His education started with this bookMutual Funds for Dummies
Books Jim recommends as foundational reading to understand personal financeThe Only Investment Guide You'll Ever Need The Millionaire Next Door The Coffeehouse Investor The Four Pillars of Investing
White Coat Investor advice for a medical studentTry to spend as little as possible. Every dollar you spend in medical school is going to be 3 dollars you pay back later This is they time you're expected to be poor. Be frugal Your specialty choice has a huge effect on your future financial life. Pick the one you will be able to work at the longest that makes you the happiest.
Advice to a young doctorThe year that matters most in your financial life is your first year as an attending physician. That year sets habits. In med school and residency, have a plan in place for your first 12 attending paychecks. In the first few years after residency, live the lifestyle of a resident while earning like an attending. This can lead to rapid savings and loan repayment Embrace the habit of saving Calculate your annual savings rate/what you're putting toward retirement. Amount of annual savings divided by gross income. That number should be around 20% Look at your purchases from the point of view, "Will this make me happy?" The is the essence of budgeting: attaching your values to how you spend your money Each month, review where your money is going. Is that where you want it to be going? If it's not, make some changes. Don't buy on credit. Spending your money on payments is not what you want to be doing
Financial AdvisorsMost doctors want or need a good financial advisor The problem is that what we want is just to have a 'money guy' that takes care of all the money and we don't have to pay attention to it To make sure you're getting good advice at a fair price, you'll need at least a basic level of financial education (or at least get a second opinion) Be aware of the fees your advisor is charging. Expect at least 4 figure amounts
Starting residency. Buy or rent?Buy a home when you are in a stable professional and social situation there are high transit costs. It costs about 15% of the value of the home to make the 'round trip in and out of the home.About 5% to get in and 10 % to get out. If you're not there long enough for the home's appreciation to make up for that 15% loss, you're probably going to come out behind Homes appreciate about 3% per year If you're in a 3 year recency, changes are you won't break even White Coat Investor recommends most residents NOT buy a home and rent
New Attending. Buy or rent?There is a good chance you will change jobs in the first few years This is not the most stable professional time Make sure the job work for you before you buy a house Rent for the first 6-12 months You should still be living like a resident during this first year Buy a home when you are in a stable professional and social situation
The "Point of Enough"If you don't define it, it will always seem like a number that's twice what you have Take how much you spend in a year and multiply it by 25. When you have that in assets, you have reached finically independence.
Real estate investingOwning actual property is to the only way to do it. Other options include..... The easiest way is the REIT. Real Estate Investment Trust index fund. Syndicated real estate
Pay Down Debt vs Invest in the MarketDoing either one will increase your net worth (unless the market tanks) Focus on what percentage of your income is going toward building wealth rather than what compartment that wealth building is going into Student loans have a few negative aspects: You can't deduct the interest when you're an attending; student loans tend to have high interest rates. Try to get rid of student loan debt within 2-5 years after residency
Jim's Ideas on Giving/PhilanthropyGood for the soul Develops a stewardship mentality Giving money away sends a message to the subconscious that you have enough - you can give some away and still be OK It keeps you connected to the rest of the world It can make your portfolio more tax efficient
How to master CPRERCAST add
Little things can make a big difference when it comes to running a code. EMS director and CPR aficionado Bill Reed gives a primer on High Performance CPR.High Performance CPR core principles Rate = 110 (100-120). Metronome set at 110. Depth = 2.0-2.5 inches. Full recoil (no leaning). Focus on rate & depth. Listen for 15 second countdown warning of upcoming compressor switch. Change compressors at 2-minute intervals/cycles. Whenever possible, compressions performed from patient’s right side and new compressor comes in from the previous compressors right side. Opposite is true for left sided compressions. New compressor to “hover” over chest during rhythm check and/or defibrillation. No more than 5 second pauses for compressor change or rhythm checks. Immediately resume CPR after defibrillation (no pulse checks) or when rhythm check is complete.
Airway/RespiratoryNRB or nasal cannula at max flow initially. BVM when available. Rate = 1 breath every 10 compressions (unsynchronized). Volume = no more than ½ ambu bag. ETI when feasible or if no ROSC by 6-8 minutes as resources allow. ETCO2 monitor connected as soon as feasible. ETI should be accomplished by a provider other than code lead. Hands off patient and/or airway device at 2-minute check. Monitor/Defibrillator Attach as soon as possible. Standard pad placement. If witnessed VF while pads were in place for another reason, immediate charge and defibrillate. Otherwise, ensure CPR for at least 30 seconds before delivering any defibrillations. Pre-charge defibrillator 15 seconds prior to 2-minute checks. If non-shockable rhythm at 2-minute check, “dump” charge by pressing the decrease energy selection button. If shockable rhythm at 2-minute check, immediately defibrillate & resume CPR (no pulse checks). If VF on rhythm check at 6 minutes (third cycle), immediately defibrillate, then roll patient 30 degrees towards new compressor, attach new posterior pad slightly below and medial to the patients left scapula, roll patient back and resume CPR. Attach new anterior pad over left superior chest. Connect new AP pads to new monitor/defibrillator. At 8 and 10-minute checks (fourth & fifth cycles), pre-charge and defibrillate with new AP pads & monitor/defibrillator set at max joules. At 12-minute check (sixth cycle), pre-charge both defibrillators to max joules and defibrillate both “simultaneously” if patient is still in VF. One operator, two fingers. Caveats Changing to AP pads and/or double sequential defibrillation (DSD) is only for refractory VF. If VF converts with standard pad placement, AP pad placement, or DSD, use that pad placement and energy setting for recurrent VF defibrillations
Venous AccessIO is faster than IV. IV can follow IO. Central venous access should be accomplished by a provider other than the code lead. Drugs Know your rhythm before giving drugs! That tachycardia might be SVT or something that might not take kindly to a bolus of epinephrine Epinephrine Goal is for 3 doses in first 10 minutes. Can give at 2,4, & 6-minute checks or whatever time interval is most easily accomplished. After 10 minutes, goal is for Epi every 5 minutes. Amiodarone (for VF) Goal is for 2 doses in first 10 minutes. 300mg first dose and 150mg second dose. Can give at 2 & 6-minute checks or whatever time interval is most easily accomplished. Code Lead & Code Scribe/Time Keeper Confirm/ensure metronome use & appropriate CPR depth & rate. Confirm/ensure appropriate BVM or BV ET Tube rate and volume. Confirm/ensure ETCO2 connected and documented. Notify team of impending compressor change and rhythm check 15 seconds prior to the end of the 2-minute cycle. Confirm/ensure defibrillator is pre-charged. Interpret rhythm. Instruct defibrillator operator to deliver shock (or deliver shock if code lead is the operator) after confirming no team member is touching the patient. Confirm/ensure resumption of CPR and BVM after rhythm check and/or defibrillation. Request and confirm drug delivery at appropriately intervals. Confirm/ensure documentation of rhythm(s) and drug doses. Ensure all pauses are less than or equal to 5 seconds (use 5 sec verbal count down).
When can you shower after stitches?ERCAST addIn this episode When is showering OK after stitches? What type of ointment should be placed on a laceration to promote healing? Is there an advantage to using antibiotic ointment over petroleum jelly on a non infected laceration? How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon? What type suture to use for extensor tendon repair. How long does one have to wait to take a shower after getting stitches? There is limited data addressing this question, but based on the data we do have, showering after 48 hours is probably OK. Even the NHS thinks so. It may be perfectly fine to shower even sooner, but there's no evidence that gives a time cutoff for optional showering. Note- showering does not mean submersion and it certainly doesn't mean getting in a hot tub. Second note- the intent of this podcast it for medical providers to understand the medical literature and differing opinions on this question, not direct medical advice to patients. What should you use to dress a wound? Keep it moist. Don't let the wound dry. Lungs do the breathing, the wound needs to be smothered. Petroleum jelly is fine. Antibiotic ointment on a non infected wound does not confer extra benefit and may actually lead to worse outcomes (hypersensitivity) A 1995 study found that using antibiotic ointment on acutely sutured traumatic lacerations decreased the incidence of 'stitch abscess' but otherwise did not improve outcome for more severe infectious, such as cellulitis Non adherent dressing, absorptive dressing, then overwrap. Many dressings incorporate all three of these in one product How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon? Our interviewed expert says he repairs anything 25% or greater In Roberts and Hedges it says repair is optional if the laceration is less than 50% of the cross-sectional area of the tendon. A study that surveyed hand surgeons on flexor tendons found that some surgeons repair all of tendon lacerations, some only if they were more than 50% PMID: 7606610 If you’re wondering if that injured tendon needs repair, if it’s a little divot, probably not. When you get into the 25-50% range, possibly. If in doubt, splint and refer. What type suture to use for extensor tendon repair Many options Avoid Vicryl. It will break down too fast (2-3 weeks, not long enough for the tendon to heal) Nylon commonly used Our consultant prefers 4-0 Monocryl or PDS II. They will both dissolve but maintain tensile strength for a long enough the for the tendon to heal References
Showering after laceration repairHsieh, Pei-Yin, et al. "Postoperative showering for clean and clean-contaminated wounds: a prospective, randomized controlled trial." Annals of surgery 263.5 (2016): 931-936. PMID:26655923 Toon, Clare D., et al. "Early versus delayed post‐operative bathing or showering to prevent wound complications." The Cochrane Library (2015). Full text link Harrison, Conrad, Cian Wade, and Sinclair Gore. "Postoperative washing of sutured wounds." Annals of Medicine and Surgery 11 (2016): 36-38. Full text link
Keeping the wound moist to promote healingDyson, Mary, et al. "Comparison of the effects of moist and dry conditions on dermal repair." Journal of investigative dermatology 91.5 (1988): 434-439. Full text link Dire, Daniel J., et al. "Prospective Evaluation of Topical Antibiotics for Preventing Infections in Uncomplicated Soft‐tissue Wounds Repaired in the ED." Academic Emergency Medicine 2.1 (1995): 4-10. PMID: 7606610
Contact Dermatitis OffendersFransway, Anthony F., et al. "North American contact dermatitis group patch test results for 2007–2008." Dermatitis24.1 (2013): 10-21 PMID: 23340394 Common contact allergens explained The Dermatologist 2014
3 Good ThingsERCAST add
Every year on Thanksgiving I call up a few friends, usually different people each year, and tell them I am thankful for their friendship. Why do I do this? Is it for them, for them to get a warm glow of being appreciated? Not really, but that’s a nice extra effect. The goal of it is for me, to act as a reminder of the amazing things we get to experience in life, friendship being one of if not the greatest.
This is just one small thing on one day of the year. But what if you did something like this, just in your own head, every day?
The Study: A qualitative analysis of the Three Good Things intervention in healthcare workers. Full text link
The Intervention: Daily email reminders asking NICU staff to reflect on: what are the three things that went well today and what was your role in bringing them about.
The Results: There were three main themes in the answersHaving a good day at work Having supportive relationships Making meaningful use of self-determined time
Mentioned in this podcastThe 5 minute journal
Caring for Autistic PatientsERCAST add
If you’ve ever cared for an autistic patient, I suspect you have seen that there are stress points for you, the patient, the family, staff... everyone involved. A medical facility, especially a hospital or emergency department, is an extremely challenging environment for someone with autism. As medical providers, we have little to no training in this and usually the best we do is try and get through it. Surely there must be a better way of caring for autistic patients than what most of us do which is, let’s be honest, figuratively hold our breath and wait for it to be over.
Our guest today is Dr Heidi James. Heidi is a general practitioner working in Moncton, New Brunswick, Canada. She wears a lot of different hats in her career: office practice, inpatient care, and medical education. But the focus of this conversation is her experience raising an autistic child, her son Jonas, specifically when Jonas the medical system meet.Heidi James' 7 insights on caring for autistic (or non-verbal developmentally delayed) patients in the emergency department We don't want to be in your department We're only here because we've run out of options or ideas. We will pay for this disruption in routine and upheaval for days to come in increased disruptive behaviours, bad sleep, and eating habits. We don't necessarily know what's going on, but we know that something is going on. We're here because we're desperate. Behavior is communication Behavior if very often an attempt to communicate (and it may work well in their usual environment; i.e. banging your head against the wall to let your caregivers know you need to have a bowel movement) Communication: find out from caregiver how they communicate: Signs? Assisted communication devices? Picture exchange communication systems? Wing and a prayer? Receptive language is often better than expressive language. Family or caregivers who know the patient are your allies We're intimately attuned to subtle changes in behaviour, know the medical history, and can make a suggestion for how to minimize disruptive behaviors. We're tired. Really tired. We're scared. More than a few of us have huge chips on our shoulders. It takes a ton of effort to be positive and pleasant when you spend hours a day cleaning up poop and years not sleeping. Remaining a non-bitter, decent human being takes hard, deliberate work. Please be patient if we direct that anger/frustration at you Quiet and secure is best Noises, lights, new faces, temperature changes, strong emotions, new smells - any one of these, let alone all of the them, can overwhelm the nonverbal patient with sensory issues. The ED is a sensory nightmare. It’s next to impossible in busy ER, but whatever accommodation can be made, try to place the patient in a quiet and secure spot. The better the first experience, the easier any subsequent ones will be. Calm voices when possible. Ask family member how to best approach pt. Many non-verbal patients are runners or elopers. Please don't lose them. Restraints and sedation are better than finding someone on the highway. Don't assume quality of life I was in the ED doing an admission just after a man with severe autism coded. My colleague/friend wanted to talk about it. She said, "It's probably for the best, he had no quality of life". I almost burst into tears. While I know that that's part of the working through bad outcomes scenario, all I could think was "My son watches the same episode of Dora everyday, eats dog poop, sleeps 3-4 hours per night and is the freaking happiest person I know. He has an amazing quality of life by his standards, but a shitty one by other people's standards." Keep these thoughts to yourself We dedicate our lives to these people. They matter. Deeply. You invalidate us as well with those comments. It's really hard for you It is challenging to care for these patients in your department. They can't communicate. Often it's the adult in crisis, and there's no family left anymore. These pts are scary when they're agitated You have to rely on tests and often poor collateral history It's can seem like veterinary medicine-there will be no verbal cues to help you. Remembering that these patients are, or hopefully were at some point, deeply loved might help you help them. Ketamine Have a low threshold for using ketamine to do procedures or perform diagnostic studies. Before sedating, ask the caregivers if there are any other tests that need to be done (such as blood tests) Bonus pearl Remember to find out it if your patient with autism can/will take meds orally. Some won't swallow pills and need suspension. Other won't take pills or suspensions
Beating Stress and the Hot Offload with Ashley LiebigERCAST add
Ashley Liebig is a HEMS Flight Nurse and Helicopter Rescue Specialist with Austin Travis County STAR Flight. Prior to her flight and rescue career, Ashley served in the US Army as a combat medic with the 101st Airborne Division. She is known around the world as a teacher of managing the stress response, both as someone who has approached it analytically as well as developed tools to mitigate the detrimental aspects of stress out of sheer necessity.The Hot Offload
Following an intense or stressful situation, employ the 'hot offload'. This is different from a formal debriefing where all of the steps are reviewed, improvements considered, etc.
Hot offload PrinciplesA quick moment of diffusion Get out the facts of what happened What did you see, hear, taste, touch, smell immediately after the event Reaffirming the memories and also exploring potentially false thought processes Discuss feelings of guilt within the confines of the small unit that was involved
Hot Offload StepsBad thing happens Team leader gets the group together Group goes through what they saw-the raw facts of the event In the hot offload, there isn’t time for could have, should have, would have. We usually don’t know if one particular action would have really made a difference Team leader does a quick check in - are you OK to continue working? The team leader may have to pull someone out of work if they observe that that person is not functioning well after the event Ashley's three techniques for managing stress
Cognitive reframingChange your perspective/mindset to make a negative situation into a positive situation. Finding opportunities in what at first appears to be something negative When bad things happen, there is a void created for you to fill with new opportunities Ashley recommends this 2 minute podcast clip by Jocko Willink on how to deal with failure and bad situations. In summary, when someone (and the someone can be you) presents you with a problem, respond with, "Good." When things are going badly, there will be some good that comes from it.
Visualization and rehearsalThis can inoculate you against the stress that arises in critical and high stakes situaitons
Mindfulness meditationAshley likes the Headspace App Ashley’s Credo Work Hard, Be Respectful, Be Kind
Also mentioned in this podcast
Liz Crowe- we talk a lot about burnout but little regarding how to prevent it
Jocko Willink Podcast Clip
Jocko Willink on the 12 aspects of an effective leader
Gunshot to the Groin with Kenji InabaERCAST add
Dr Kenji Inaba is a trauma surgeon at the University of Southern California. He is also the director of their surgical ICU, one of the most widely published trauma researchers with over 400 publications, and a reserve officer with the Los Angeles police department. You'd think with that kind of background, he would be macho, arrogant, and in your face about how awesome he is but, in fact, he’s just the opposite. Humble, kind, thoughtful and just about the greatest guy you’ll ever meet. In today's episode, we discuss junctional bleeding: Bleeding from an area that is a junction of an extremity and the torso (and neck) that is not amenable to hemorrhage control by tourniquet.A patient arrives with a gunshot wound to the groin. The paramedic is holding pressure with a stack of gauze but it's obvious that bleeding isn't controlled. Here are the next steps Remove the gauze Assess the injury Where is the hole and what kind of bleeding is coming up? If there is sustained bleeding, apply pressure to the specific point of bleeding - ideal if you can compress proximal to the hemorrhage site. Using diffuse pressure with the palm of your hand in the general vicinity of bleeding may be less effective. If bleeding continues or you need to free up your hands, consider placing a Foley catheter in the wound. The best kind of wound for a foley catheter is one that's just big enough to allow entry of the catheter (so it balloon stays in the cavity once it's inflated) Placement of a Foley catheter to control junctional bleeding as described by Kenji Inaba Use the largest Foley catheter that you have. It's not the size of the catheter that's so important, it's that larger catheters will have more balloon volume Ask for mulipies catheters because one might not provide hemostasis Place the Foley in the hole (bullet or stab wound) and go all the way into the bleeding cavity. Slip the catheter in as deep as it will go Inflate the balloon with saline (or some sort of fluid). If the bleeding hasn't stopped after 20-30 cc of fluid in the balloon, you may need to place a second catheter Clamp across the Foley tube (so blood doesn't come back through the catheter) May need to stitch the skin so the balloon doesn't pop out Another option that Kenji uses are the XSTAT pellets Kenji's opinion on junctional tourniquets (examples Combat ready clamp, SAM junctional tourniquet ) They work Some are quite bulky, a lot of material in your way during a resuscitation If you work in a place were you need to apply pressure and get your hands free and have the capacity to store them, not a bad idea. In Kenji's ED, OR, and ICU, he doesn't see much return on investment
Long term health of patients vs. Short term risk to doctorsERCAST add
What is your real motivation when making medical decisions? Is it 'what's in the patient's best interest' or is it 'what will keep me from getting sued'? The reflexive answer is, of course, the former, but if you really do some soul-searching, there's probably a bit of the latter as well. In this episode, Mike Weinstock, author of Bouncebacks, and Bouncebacks Pediatrics, discusses why we sometimes have our priorities misaligned with the patient's and how that doesn't need to be the case.
Along with Amal Mattu and Erik Hess, Mike has recently published an article titled How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? (link). The study's conclusion is this: A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician’s short-term concern of their own risk to the patient’s long term health.
An example of where this sort of thinking comes into play is with the evaluation of patients with chest pain. Should they be admitted to the hospital? Are they safe to go home? Before we can answer either of those questions, we first need to address the elephant in the room...
What is an acceptable miss rate for chest pain?
Than, M., et al. "What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the Emergency Department?: a clinical survey." International journal of cardiology 166.3 (2013): 752. PMID:23084108Survey of 1029 emergency department clinicians. 395 comfortable with a 1-2% miss rate 267 comfortable with < 1% 331 only comfortable w < 0.1%
Putting that last number in perspective, that's admitting 1000 patients to find one with cardiac disease. Is that a good return on investment or wise stewardship of health care resources? I think the answer is no. There are several reasons for this. The first is that being admitted to the hospital is not a benign event.
What is the chance that a patient will be harmed by hospitalization?
James, John T. "A new, evidence-based estimate of patient harms associated with hospital care." Journal of patient safety 9.3 (2013): 122-128. PMID: 23860193Estimates a lower limit of over 200,000 deaths per year related to the deleterious effects of hospitalization
It's no secret that hospitalization can be dangerous, but it can also be extremely helpful in the properly patient. So in a patient with chest pain who has two negative troponins and a non ischemic EKG, what is the short term risk of clinically relevant adverse cardiac event (CRACE)? In other words, if we hospitalize patients with these factors (negative EKG and enzymes) what is the likelihood that something bad will happen in the next few days that could be mitigated by hospitalization?
Weinstock, Michael B., et al. "Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission." JAMA internal medicine 175.7 (2015): 1207-1212. PMID:25985100This study sought to determine the risk of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization in patients with negative serial troponin, non concerning initial ED vital signs, and nonischemic, interpretable EKG. Over 7,000 chest pain patients admitted (non ischemic EKG, negative serial troponin) 0.06% incidence of CRACE during the hospitalization So over the few days that a patient with non corning EKG and negative enzymes is in the hospital, there was a 6 in 10,000 chance of a catastrophic outcome This is different than what's being asked by the HEART score. HEART is looking for the risk of major adverse cardiac event (MACE) in 6 weeks.
Taking all of this into account, how does Dr. Weinstock approach shared decision making?If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk The Weinstock Credo: Don't practice defensive medicine. Document "defensibly"
Also mentioned in this episodeBrown, Terrence W., et al. "An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers." Academic Emergency Medicine17.5 (2010): 553-560. Full article link Have a good time, all the time
Editors note: Show notes are meant to complement the podcast and do not represent a complete synopsis of what is contained in the audio.
Precise CommunicationERCAST add
Have you ever watched a volleyball game and seen the ball fall between two players? What happened there? It was probably inadequate or insufficient communication as to who was going to make the play. The same thing happens in almost every professional arena: mistakes are made because of poor communication. In this episode we discuss three tools to improve how we relay information to each other, eliminate ambiguity, and the biggest goal of all - improve patient safety.
Tools discussed in this showThree way repeat backs Phonetic clarification Clarifying language with numbers Using a dry erase board in the resus bay Posters in the resus bay with simple but important checklists
Links mentioned in this showReuben Strayer's intubation checklist ERcast on facebook ERcast on twitter Dislike both Facebook and twitter. Just use our contact page Three way repeat backs
Sender: Gives the initial information
Receiver: Repeats information back
Sender: if the repeated information is correct, responds with, "That's correct."
Using the phrase "that's correct" takes away the vagueness that can happen with words such as right, OK, yup, got it, etc.Phonetic clarification
Use the phonetic alphabet to spell out easily misspelled or misunderstood words. For example, my name is often misspelled, so I will say, "It's Orman, O-R-Mike-Apple-Nickel." There are many phonetic alphabets out there, and you don't have to use one in particular. Just use what makes sense to you and is clear to the listener.Clarifying language with numbers
When there are numbers that sound alike such as 15 and 50, say the number and then say the digit. "Please give fifteen milligrams of drug X, that's one five milligrams"Using a dry erase board in the resus bay
I use the board to write my induction, paralytic, and post intubation medication plan. This is discussed out loud with the team while I'm writing it out. I use Reuben Strayer's intubation checklist as my reference. Here is an example (written on my board at home, not an actual patient).Posters in the resus bay with simple but important checklists
It's amazing how much can be missed in a trauma resuscitation. Going back through the primary and secondary survey, step by step, can help organize your management and keep you from missing critical issues. Here are two posters in my favorite resus bay:
Alcohol, c-spines, and lots of pusERCAST add
A day late and a dollar short, but here it is, the Ercast summer Journal Club. As per usual, boy genius Adam Rowh, MD is in the house to give his take on the medical literature. In this episode, we discussCervical spine clearance in the intoxicated patient (can you remove the collar if they have a negative CT?) Is there utility to giving antibiotics to patients with simple cutaneous abscess? Thrombolytics don't give long term benefit to patients with submissive pulmonary embolism Haloperidol is good for what ails you (if you have gastroparesis) Steroids for bronchitis
Also mentioned in this showBoneyard RPM IPA Follow us on Facebook. It's the new information portal for updates, questions, etc. If you want to contact me personally, use the contact link on this webstie Now on to the education.... Do patients with simple abscesses need antibiotics?
The answer for much of the antibiotic era has been no. I and D is sufficient treatment. But with the rise of MRSA, that thinking has been questioned. A paper by Talan in 2016 investigating TMP-Sulfa vs placebo for uncomplicated skin abscess suggested that TMP-Sulfa conferred a higher cure rate after I and D. Now comes a study of similar ilk but an additional treatment arm.
Study BasicsTitle: Daum, Robert S., et al. "A placebo-controlled trial of antibiotics for smaller skin abscesses." New England Journal of Medicine376.26 (2017): 2545-2555.PMID: 28657870 The patients: 786 patients with abscesses 5 cm diameter or less. The treatment: After I and D placebo, patients received either placebo, clindamycin, or TMP-Sulfa Primary endpoint: Clinical cure. This includes improvement of the treated abscess but ALSO no new abscesses forming elsewhere (that will come into play later) The results: Compared to placebo, both clindamycin and TMP-Sulfa improved short-term outcome. Clinical cure was 83% clinda, 81% TMP-Sulfa, and 69% placebo. NNT of 8. There was not much difference between the different antibiotics, but big a difference compared to placebo
Looking under the hood (examining the details)Treatment effect was only when staph was the culprit. When there was no staph isolated, the outcome was not influenced by antibiotics Average surrounding erythema was over 2cm. This suggests that there was some cellulitis in these patients. Prior to this study, the common practice was to treat these patients with antibiotics. We recognize that it's not always easy to delineate between redness from the abscess itself and spreading cellulitis. Our point of contention, that these abscesses also had cellulitis, may be making a big deal out of a small thing (or it could be the most legitimate criticism of the paper). Treatment failure was mostly formation of new abscess and not worsening of the original abscess. While this is certainly a measurable effect, is it really a treatment failure? We argue that it is not. What's probably happening here is decolonization on some level. That is pure conjecture, of course, and it's certainly possible that there was autioinfection from the main abscess. Our bias: We don’t want to give extra antibiotics. Coming into this paper, we were looking for any faults in the study that could confirm an 'antibiotic stewardship' approach. If this was a paper showing even a small benefit for thrombolysis in the treatment of pulmonary embolism, we would look at in the exact opposite manner-where is the signal of benefit that says we might help patients. Will this change our management? Both Rob and Adam say it will not. We will continue to treat simple cutaneous abscesses (without surrounding erythema) with I and D alone. If the abscess is a recurrence or it is a patient with multiple abscesses, we will consider antibiotics. C-spine clearance in the intoxicated patient
An intoxicated patient with moderate trauma has a pristine looking, completely normal, CT of the cervical spine. Do we need them to continue wearing their cervical collar until clinical sobriety? Enter our next study
Study BasicsTitle: Schreiber, Martin, et al. "Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey." (2017). PMID: 28723840 The patients: About 10,000 moderate trauma patients, of who approx 3000 were TOX positive (alcohol, drugs, or both). The average injury severity score was 11 (moderate trauma). Intervention: CT cervical spine Primary outcomes: Incidence and type of cervical spine injuries, accuracy of CT scan, and the impact of TOX+ on the time to cervical spine clearance The results: In the TOX positive group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable cervical spine injuries missed by CT (NPV=100%). One patient in the Tox + but CT negative group had a central cord injury. When CT cervical spine was negative, TOX + led to longer immobilization vs sober patients (mean 8 hrs vs 2 hrs, p12hrs) in 25%. Author take home: CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization
This conclusion mirrors the EAST guidelines on cervical spine collar clearance in the obtunded adult blunt trauma patient:
In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. This conditional recommendation is based on very low-quality evidence but places a strong emphasis on the high negative predictive value of high quality CT imaging in excluding the critically important unstable C-spine injury.Haloperidol for Vomiting
The lament for droperidol's absence from our pharmacopeia continues unabated, yet there is another shining star: haloperidol. What's old is new when it comes to treating severe nausea and vomiting. Long recognized in the palliative care world as the cat's pajamas for management of nausea, haloperidol is finally getting the recognition it deserves.
The study: Ramirez, R., et al. "Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department." The American journal of emergency medicine (2017). PMID:28320545
The patients: Retrospective study of 52 patients with diabetic gastroparesis treated with 5mg IM haloperidol.
The comparator group: The SAME PATIENTS on ED visits when they didn’t get haloperidol! You can't get better matching characteristics than that.
The results: Using haloperidol in this group of patients decreased amount of opiates given and admissions but not ED or hospital length of stay. There were no complications seen in patients given haloperidolSystemic lytics don't work for intermediate risk PE
This has been a subject of much debate over the past decade and there has been signal that there may be a benefit in function outcome when thrombolytics are given to so-called intermediate risk pulmonary emboli- not hypotensive but right ventricular dysfunction and a positive biomarker. The biggest research article to date says lytics don't improve outcome.
The study: Konstantinides, Stavros V., et al. "Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism." Journal of the American College of Cardiology 69.12 (2017): 1536-1544. PMID:28335835
The patients: About 700 patients with intermediate risk PE given either Tenecteplase of placebo. Intermediate risk PE defined as RV dysfunction confirmed by echocardiography or spiral computed tomography of the chest. Myocardial injury confirmed by a positive troponin I or T test result.
The results: At 3 year follow up, there was no significant difference in mortality, functional limitations, pulmonary HTN, or RV dysfunction.
Our take home: When we first saw this paper, we were giddy because here was evidence that would show, once and for all, that lytics were an effective treatment for this cohort. The cold hard data says quite the opposite: lytics don’t make a difference in long term outcome. The best evidence we have to date suggests that there is no justification to give systemic thrombolysis to a stable patient with intermediate risk PE. Will catheter directed lysis prove any better, or are there certain high risk groups under the 'intermediate' umbrella who would benefit? Time will tell.Prednisone for cough
The study: Hay, Alastair D., et al. "Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial." Jama 318.8 (2017): 721-730. PMID:28829884
The patients: 400 patients with cough for less than a month and at least 1 lower tract symptom like phlegm, chest pain, wheezing or SOB in the past day. Patients received either 40 mg of prednisolone or placebo daily for 5 days. The primary outcomes were duration of cough and mean severity of symptoms on days 2 to 4.
The results: Steroids did not make a difference
Our take home: WTF!? Of course steroids didn’t work! Only 6 percent of patients had wheezing and only a handful had crackles. Does a patient with an undifferentiated acute viral respiratory infection benefit from steroids? Apparently not. We tend to prescribe patients to these patients who DO have wheezing, but this supports our practice of not using them in patients who don't.
What you don't know about Wernicke's encephalopathyERCAST add
Megan Spyres, toxicologist and emergency physician at LA County-USC, gives a primer on diagnosing and treating Wernicke's encephalopathy. The title of this post "What you don't know about Wernicke's encephalopathy" is more from my perspective than a commentary on what you, the listener, may know. After all, you might be a genius when it comes to this disease. For me, this has always been confusing and difficult to diagnose. So let's sharpen our clinical acumen and learn why neglecting thiamine can be a really bad thing. Special thanks to Dr. Anand Swaminathan for his journalistic excellence in putting together this interview.Pathophysiology secondary to thiamine deficiency (vitamin B1). Thiamine is a cofactor for pyruvate dehydrogenase. This enzyme is needed to take glucose from anaerobic glycolysis into the Krebs cycle (where we make the majority of our ATP) pyruvate dehydrogenase converts pyruvate (the end product of glucose metabolism in glycolysis) to acetyl co-A. Acetyl co-A is the entry point into the Krebs Cycle. if there is no thiamine, there is no Acetyl co-A... no Krebs Cycle... no ATP. The heart and brain get quite upset and function poorly when they don’t have ATP we only have a few weeks of thiamine reserves (best case scenario) Clinical Presentations
Cardiac: Wet beriberihigh output heart failure. Fatigue SOB, peripheral edema
CNS: Wernicke's encephalopathyophthalmoplegia ataxia altered mental status/confusion/memory problems
Extra nuggetsIt would be nice, in a clinical sense, if patients presented with all elements of this triad, but the overwhelming majority do not (there may be just one or two) Wernicke's encephalopathy can progress to Korsakoff syndrome - an irreversible anterograde amnesia. May also include confabulation, apathy, lack of insight. In addition to the above findings, there may also be absent reflexes on physical exam
How common is Wernicke's encephalopathy?estimated to be present in 2% of the US population
Who is at risk?insufficient intake insufficient absorption enhanced elimination
Specific groups who are at risk for thiamine deficiencyChronic Alcoholics: poor nutrition, poor absorption Bariatric surgery, AIDS, malignancy, hyperemesis gravidarum Insufficient intake: eating disorders, prisoners, institutionalized elderly Enhanced elimination: patients on furosemide
Evaluating for Wernicke's encephalopathyIt’s an easy disease to overlook. Consider in an alcoholic patients with multiple presentations with confusion Do a good neurologic exam. Don’t blow off persistent ataxia, especially when the intoxication has resolved to the point where the patient can be discharged In 1997, Caine et al suggested that the diagnosis could be made with two or more of the following: dietary deficiencies oculomotor abnormalities cerebellar dysfunction either an altered mental state or mild memory impairment
Treatmentgive thiamine in the presence of ETOH, thiamine absorption is reduced by up to 50%. Don't think you will be able to rapidly correct this disease with PO treatment alone 100mg IV is good for prevention and might protect patients for at least a week. This dose is not, however, considered sufficient for treatment treat with 500mg IV thiamine three times daily for 2-3 days, then 250mg IV TID for 3-5 days
Does thiamine need to be given before glucose?a glucose load will increase thiamine requirements. historically, it has been thought that giving a load of glucose (or dextrose) might ‘push patients over the edge’ into encephalopathy. There’s no evidence that this occurs in patients who aren’t already overtly thiamine deficient.
Bottom Line: Wernickes encephalopathy is easy to treat but also easy to miss. When we miss it, our patients can suffer
Conquering Night Shifts and Soft Tissue Ultrasound with Mike MallinERCAST add
Mike Mallin is a legend in emergency ultrasound but, by day, he's a regular guy and community ED doc. In this episode, Mike and Rob talk aboutmaking the change from an academic to community medicine job working in a place that sparks joy working locum tenens soft tissue ultrasound looking for abscess placing peripheral IV catheters under ultrasound guidacne how they approach night shifts (both single and stacks of shifts) patient handoffs Soft tissue ultrasound
This is one of Mike Mallin's favorite exams, because no matter how good he thinks he is at guessing how much or if any pus is underneath the skin, he's often surprised when looking with ultrasound. A landmark study by Tayal in 2006 found that the introduction of soft tissue ultrasound into an ED evaluation for a skin and soft tissue infection changed management 56% of the time. Some patients who docs thought needed drainage didn’t and some that docs did not think needed drainage did.Pearls when looking for an abscess Compress with the probe: Pus can look a lot like surrounding tissue - especially nasty, thick MRSA pus. Sometimes the only way to see the pus pocket is to compress. What you're looking for is the swirl sign (sometimes called the 'squish sign') Use Color Doppler. Make sure that dark pocket of fluid you’re about to incise isn’t a AV fistula, or a random artery or vein. An 11 blade in a vascular structure is considered bad form. Look for Air: While looking at the infection, beware of air bubbles in the skin, they- along with fluid tracking on the fascial planes, can tip you off to gas forming bacteria. While that doesn’t always mean necrotizing fasciitis, it should get your attention. Unless there is already a hole in the skin for air to get in, these patients probably need a surgeon's hands on them.
Soft tissue air. Ultrasound from Joseph Minardi
Another example of necrotizing fasciitis on US from the EDE blogRob's Patient Handoff Macro This is a [ ] year old [ ] who presented to the emergency department with a chief complaint of [ ]. Patient care transferred from Dr. [ ] at [ ]. Presenting symptoms: [ ] Workup to this point: [ ] Pending studies: [ ] Plan at time of sign out: [ ] Study results: [ ] Patient reassessment: [ ] Plan: [ ]
Getting SuedERCAST add
This is not an easy episode. It's not easy because a doctor gets named in a lawsuit, a patient has a bad outcome, and it openly discusses some of the systems failures we have in medicine. If that's enough to turn you off, close the page and go about your day. You'll probably be happier for it.
Still here? Well, here's what we've got... Cam Berg is arguably one of the brightest stars in emergency medicine (or all of medicine if you ask me.) Even that level of excellence, however, didn't stop Cam from being named in a lawsuit when a patient had a catastrophic outcome. This case involves a series of events that include: hypertension, IV hydralazine for asymptomatic hypertension, boarded patients, stroke, thrombolytics, brain bleeds, and the collateral effects of getting sued.
Peeing Blood and the Pesky ErectionERCAST add
Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer.
Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised.Stuff Adam and Rob have discovered recently and are really digging Rob Dermastent Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls of heavenly delight I use during shifts (and home, and exercise, and so on). This Tono-Pen Adam Wearing gloves while eating a sandwich Topical TXA for a persistently bleeding biopsy site in a patient taking rivaroxaban Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in the nebulizer basin either with or without bronchodilator Treating Priapism Patient presents with persistent painful penile erection. Anesthetize the penis, sterilize the area of corpus cavernosum you are going to drain. How one numbs the penis for this procedure is a matter of great debate, meaning there is no best answer. Some espouse a dorsal penile nerve block while others favor local anesthesia at the site of injection. I prefer local infiltration at the site of injection and have found it to be more reliable than trying to get the whole penis numb. Mix up a solution of dilute phenylephrine. This is your vasoconstrictive agent. The end goal is to dilute 1mg of pheynylephrine with 10 mL of normal saline (or 9.9 mL if you're a purist). This gives a concentration of 100mcg/mL ( the recommended dose from the American Urologic Association is actually 100-500mcg/mL, giving a significant margin of error). The phenylephrine you have in your department is most likely 10mg/mL, so you will end up drawing a tenth of a mL. Getting the vasoconstrictive agent mixture correct seems to be one of the more anxiety provoking aspects of this procedure. There are lots of ways to make your mixture, the most straightforward method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB syringe. Into that same syringe, draw up 0.9cc of saline. Now you have a total of 1cc total volume. Add that to 9cc of saline and you are at the desired 100mcg/mL concentration. When you've got this task completed, set this syringe to the side. You're going to need it shortly. Pro tip: label the syringe after creating the dilute phenylephrine. Attach an 18 or 19 g butterfly needle to a large syringe Inset the butterfly needle into the corpus cavernousum at the lateral base of the penis. It doesn't matter which side, each side connects to the other. Your entry point is either 10 or 2 o'clock. Pull back on the syringe while advancing the needle. Once you get blood back, stop- that is your needle depth for the remainder of the procedure. Pro tip: Even though you might be tempted to use the biggest syringe you can find, like a 60cc behemoth, stick with a 20cc syringe. The bigger syringe might create too much suction, which can ruin the day. Aspirate blood. This will look thick and dark (chocolate syrup, old motor oil dark). The amount you'll be able to aspirate varies, but it's usually around 10-20cc. Keep the butterfly needle in place while you unscrew the aspiration syringe from the proximal port and replace it with your syringe with dilute pheynlephrine. Better yet, use a 3 way stopcock. On one port, you have your vasoconstrictive agent ready to go. On the other port, you can easily work the replacement of fresh aspiration syringes. Having an assistant for syringe management makes this process much easier (and safer as you're less likely to change the position/depth of the butterfly needle while fiddling about with the syringes) Inject 1mL of dilute phenylephrine into the penis. Pro tip that's probably not actually a pro tip: After injection, massage the penile shaft to get more diffuse spread of the vasoconstrictive agent. Does this massaging actually improve outcome? Unknown. The penis may now become flaccid or it may still be tumescent. If the erection does not resolve, repeat steps 6 through 8. This may take several rounds of aspiration and injection of vasoconstrictive agent. When is the penis flaccid enough that you can stop? Some say when the blood aspirated, others when the penis stays flaccid. There's not an absolute demarcation line, it's more of Justice Potter Stewart's "I know it when I see it." Milk the penis from tip to base to squeeze out residual blood. The patient can do this as well. Pro tip: After you've finished the above steps, wrap the penis in a compressive bandage like an ace wrap or Coban to prevent reaccumulation of blood. If you are unable to resolve the priapism with this technique, urology may need to take the patient to the OR Hematuria
When a patient presents with hematuria, what are the key questions to ask in the ED?Is there any associated pain? If so, you may be dealing with a stone, infection, etc. If it is painless, which is the most common situation we see, the big question is whether or not the patient is in CLOT RETENTION. Are they retaining urine or can they pee freely? The test for this is a post void residual bladder scan If they are peeing blood, but not in clot retention, they can follow up with urology as an outpatient for CT urogram, cystourethrotgam, and advanced urine testing If they are in CLOT RETENTION, you need to drain the bladder. What often gets placed is a three way catheter. These catheters are great for irrigating the bladder, but may not be sufficient to evacuate clots. Dr. Shaffer recommends placing a 22 Fr 6 eye catheter. Here's an example of a 6 eye catheter (we have no connection with the company selling these in the link provided) Once the 6 eye catheter is in, hand irrigate the bladder until there are no clots If the urine clears (cranberry colored or lighter), pull the catheter and give a voiding trial If the urine is still bloody, NOW place a 3 way catheter and admit the patient for continuous bladder irrigation. They get admitted to see if they go back into clot retention. Jess Mason and urologist Eamonn Bahnson have a master class review of placing the difficult foley in the August 2017 edition of EMRAP. Interstitial cystitis Evaluate for and treat infection Manage pain Make sure they're on an anticholinergic Follow up with urology
When Breath Becomes Air. Lucy Kalanithi InterviewERCAST add
Last summer I took a road trip to Canada and during the drive I listened to the book When Breath Becomes Air. That was a year ago, and I still think about that book, almost daily. When Breath Becomes Air is the autobiographical account of the final 2 years of neurosurgeon Paul Kalanithi life. Paul was in residency, age 36, when he was diagnosed with stage 4 lung cancer, to which he ultimately succumbed. The book tells the tale of the nuts and bolts of his treatment, his transformation from doctor to patient, but more importantly, it was about time. His time was limited, just like all our time is limited, but with a terminal diagnosis, in the face of death, he asked the question, “What makes life worth living?” What do you do with your time, what’s important? Do you work if you’re physically able, do you spend all of your remaining time with your family? Time can feel infinite, especially when you’re young, but as individuals, time is our most precious resource, and it’s a nonrenewable resource. So how do you spend it?
Paul died before completing his manuscript and his wife, Lucy Kalanithi, a Stanford internist, put it together and wrote the epilogue. Since then, she’s become a passionate a vocal advocate for helping others choose the heath care and end of life experiences that best align with their values. In May 2017, at Essentials of Emergency Medicine in Las Vegas, I sat down with Lucy for a live interview on why she does what she does, some of the experiences she and Paul when through, how her perspectives on life and medicine have changed, what she thinks when she sees a patient with the sniffles, what if everyone died like a doctor, and reframing the question where there is a devastating diagnosis or even a run of bad luck from, “Why me?” to “Why not me?” I’d encourage you to listen to this particular podcast episode all the way through and not in small chunks. It builds momentum as the conversation progresses and at the end, culminates in what are some beautiful words of wisdom...Life is not about avoiding suffering.
Spring 2017 Journal ClubERCAST add
It may be summer (in the northern hemisphere), but that doesn't mean we can talk all the goodness that was our spring journal club. As usual, Adam Rowh slayed the beer selection with a killer Scottish ale as well as these lovely articles. Enjoy....The papers Less is more for low back pain
Qaseem, Amir, et al. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of internal medicine 166.7 (2017): 514-530.
Driver, Brian E., et al. "Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia." Annals of emergency medicine 68.6 (2016): 697-705.
DePeter, Kerrin C., et al. "Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?." The Journal of emergency medicine 52.4 (2017): 426-432.
Full article link via Broome Australia's favorite ginger raconteur, Casey ParkerKetorolac's therapeutic ceiling
Motov, Sergey, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial." Annals of Emergency Medicine (2016).
Full article link from, yep, once again, Casey ParkerConcussion, Rest, and the 8th Dimension
Grool, Anne M., et al. "Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents." Jama 316.23 (2016): 2504-2514.
Thomas, Danny George, et al. "Benefits of strict rest after acute concussion: a randomized controlled trial." Pediatrics (2015): peds-2014.
How to learn from a lectureERCAST add
Amal Mattu stops by to talk about the best way to get the most from attending (as well as giving) a lecture. Hint, it's not the the transfer of information. Amal says that lectures have one of two purposes: to persuade or inspire.
To get the most out of attending a lecturetake notes no more than three take home points per talk when you get back home, review your notes and read the handout, source material, etc ask questions if possible do not sit passively and try to absorb information by some sort of osmotic wizardry
To get the most out of giving a lecturesimple slides without too much or complex information no more than one take home point every 10 minutes engage the audience in the discussion repeatedly reinforce the take home points practice and then practice a bit more
Links discussed in this show
P Cubed Presentations Link
Essentials of Emergency Medicine Link
Examining mental health patientsERCAST add
When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental health part of the exam, what do you look for and how do you document it? There are all sorts of different ways to go about it, but one I find particularly useful is the mental status exam. Not alert and oriented times 3 or GCS 15 mental status exam, but the one that goes by the title Mental Status Exam.
It’s an exam that is carried out by your powers of observation. There is no stethoscope, no palpation involved. You are just watching and listening. What we’re going to go through is my adaptation of the full Mental Status Exam. It’s been tweaked, added, subtracted, and modified over the years and I’ve found it helps to break down the aspects of a patient's appearance and behavior in a way that makes sense (at least to me). As I was putting this podcast together, I thought about some of the dogma that goes into any structured evaluation, meaning: these are the core elements of the exam and that’s all there is to it; it’s always been done this way and this is the best way. But there really is no evidence that performing a mental status exam in one particular way versus another improves outcome. The same could be said for many parts of the physical exam. Much like the suicide risk assessment template I use, I see this as a way to make sense of what is often an incredibly complex emergency department presentation.ED Mental Status Exam
The constituent elements are: Mood, affect, eye contact, attending to internal stimuli, thought process and content, speech pattern, grooming, and presence or absence of suicidal ideation. Let’s break that down piece by piece.
Mood and affect. These terms are confusing because they are synonyms and don’t they kind of mean the same thing? Think of it this way: mood is how the patient tells you they’re feeling and affect is what you observe. For example, mood: I am anxious, I am depressed, I am crawling out of my skin, etc. Affect: what do you observe about their emotional state. Do they appear anxious, depressed, flattened, blunted, restricted, is their affect exaggerated? Is it congruent with their mood and the current situation?
Eye contact. Do they look you in the eye, are they engaged in the conversation? Are they withdrawn and looking down/away?
Attending to internal stimuli. This is something we usually equate with a psychotic state: auditory and/or visual hallucinations. It’s being generated by their mind as opposed to an external force. Sometimes it’s pretty clear. They’re intently looking around in an empty room or carrying on a conversation when there’s no one there. Sometimes it can be more subtle and only manifested as inattentiveness with latency in answering a question or following an instruction (although that latency can have many other causes).
Thought process and content. Is their thought pattern organized or disorganized? Are there delusions or obsessions?
Speech. Is it normal content and cadence? Pressured? Super loud or super soft? Is it tangential? Tangential speech is often categorized as a thought process because it is a variant of disorganized thought, but I put it here because it's such a distinct speech pattern.
Grooming: Well kempt? Disheveled? Clothing encrusted with urine and feces?
Suicidal ideation: Present, absent, passive, active with a plan?
There are many other parts of the full Mental Status Exam, but those are the high yield aspects that I use, or at least start with. Some things like 'insight' I put in the suicide risk assessment, because that takes an involved conversation with more direct engagement to tease out, rather than easily observe.Putting it all together.
A person who is having no issues at all, completely normal exam.
Mood, baseline and neutral per patient. Affect, neutral and congruent with mood. Eye contact good. He does not appear to be attending to internal stimuli. Thought process and content normal. Answers all questions appropriately. Speech is normal content and not tangential. Grooming well kempt. Suicidal ideation denies.
Or a psychotic patient may have an exam that looks something like this.
Mood is depressed. Affect flattened. Poor eye contact. He appears to be attending to internal stimuli and is looking about the room during our conversation. He periodically turns his head to the side and yells obscenities. Thought process is disorganized and there are several seconds of latency in answering questions. There is a delusion of persecution where the patient reports being followed by the government. Speech is slowed cadence, tangential, and he gives answers that are not always relevant to the question. Grooming disheveled. Suicidal ideation: Patient does not answer questions regarding this, but presents after attempting to jump of an overpass.
This evaluation will be different for every patient and the findings aren't always easy to describe, but I find that having a standard framework makes assessment consistent, exponentially easier, and more thorough.Mentioned in this episode
Suicide Risk Assessment master page
Nasal suction. Miraculous simplicityERCAST add
It is bronchiolitis season my friends. Even I have a bit of the URI. When we’re talking bronchiolitis, the conversation is almost always about: do steroids or bronchodilators work, what to do with a touch of hypoxia. Important conversations to be sure, but the highest yield pearl I have ever received about bronchiolitis (or any pediatric URI for that matter) was given to me by pediatric emergency physician Andy Sloas. Wash it out, suck it out.
We know that babies are obligate nose breathers. When that nose is plugged, breathing is harder and they don’t eat. When they don’t eat, they get sicker. They cycle continues until they get dehydrated and REALLY sick.
Sometimes a baby with a stuffy nose who isn't eating just needs a little nasal clean out. They breathe easier, they start to eat, or drink (which is usually the case) and often can go home without any other treatment.
So if a child has a URI with a runny nose and isn’t feeding, squirt in some saline and suction out the boogers. The key is in the home care. Most parents will tell you that they’re suctioning with the little bulb suction, but they can benefit from a structured approach.Home care
How often to suction?
Breakfast, lunch, dinner and right before bed.
Before suctioning, squirt in some saline drops. You can give the parents some drops or they can buy them from the pharmacy.
Squirt in the saline drops. The child might cough. They might cough, swallow mucus, and vomit after some saline drops. All that nasal goo getting swallowed can make kids vomit, and that’s expected. Not desirable, but it happens. First saline drops, then suction. The parents might not be able to get mucous with each suction and that’s OK. It’s the repeated attention that matters.
Here is an example of a discharge instruction for runny nose treatment.
To help clear nasal secretions (nasal mucus and runny nose) spray over-the-counter saline nasal spray (or drops) into each nostril morning and night and with each feeding. After this, suck out each nostril with a bulb suction. Spraying in the saline spray will help clear the nasal mucous and loosen it up so that it can be better suctioned. Your child may gag or cough after the saline is sprayed in the nostrils, this is not unexpected. Keeping your child’s nasal passage open will help them breathe easier and make it easier for them to eat and drink.
Disclaimer: This is only an example of phrasing for discharge instructions. It is not meant as medical advice. Please see site disclaimer for further details.