EMRAP and AIR Ortho Upper Extremity (Aug 2019)
AIR: https://www.aliemu.com/courses/orthopedics-upper-extremity-2019/
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
https://www.emrap.org/episode/emrap2019august/pediatricpearls
When you have finished listening to the podcast, answer the following questions:
- Please list three things you learned from this podcast that you were not aware of before.
- Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
- What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
5 comments
Three things that I learned and how they could change my practice:
1. The origin of the cuffed/uncuffed pediatric intubation was based on the belief that children had funnel shaped trachea. CTs have proven this to not be true. I’m glad this is the case because it is another step in simplifying our practice – similarly it seems that more research has proven that MAC blades can be used to directly scoop and lift the epiglottis in children so that we can maintain expertise in our one blade of choice rather than switching to unfamiliar blades in probably the scariest resuscitation (a pediatric one). Finally, while this podcast reaffirmed my ability to use the equipment I am most comfortable with on pediatric cases as well, I would give extra attention to a step in intubation that currently is fairly thoughtless, inflating the tube. Luckily, this was simplified to say that the cuff should be inflated to the point that there is still a small air leak around it to minimize trauma on the pediatric patient’s developing larnyx.
2. End tidal capnography may be even more important than tele for our patients. While we have a dedicated Epic button now to have patient’s officially documented as needing tele monitoring in the ED (which for me has become the “this patient needs a room” button more than anything), I think that the medicolegal brief segment has elucidated the importance of monitoring in the era of hallway medicine. Some of our most high risk patient from a respiratory depression standpoint are often triaged to the hallway (very intoxicated, s/p heroin overdose +/- narcan) and it is very difficult to tie up rooms for these patients to be on end tidal capnography. Further, I’ve had several patients requiring chemical and physical restraint while still in the hallway while we make a room available for them. While our ED isn’t getting more monitored rooms anytime soon, I think we need to be extremely aware that there is a larger group of patient’s than just our cardiac patient’s that warrant formal monitoring, and really we may need portable end-tidal that syncs with our central monitors to address this safety concern. From a practice change standpoint, I think all chemically restrained patients should be formally on end tidal CO2 monitoring in our ED.
3. I’ve never heard of a dropped gallstone before. While this is definitely rare, I think we rely heavily on CTs for post-op pain/complication patients in the ER – and our surgeons certainly love imaging as well. So this is definitely a complication we have to be alert to since the gallstone will likely be invisible on CT aside from their associated abscess or fistula. While this is obviously more in our surgeon’s territory, this is a complication that would likely continue to be missed if the associated abscess if drained percutaneously rather than by performing repeat laparoscopy or laparotomy with direct visualization of the dropped stone.
Too bleeding edge – There have been a few recent cases of aortic dissection in the emergency room. Reversing anticoagulation seems like a no brainer in these patient’s, but Weingart’s segment brought up some legitimate points. After listening to this, I still think almost all anticoagulated aortic dissection patients probably still warrant reversal to limit potential bleeding and tamponade, but we should be attune to looking for and addressing the other complications (valvulopathy, cardiogenic shock from MI) as well. His point seemed to be that if you reverse them, they will likely need open cardiothoracic surgery with full heparinization in the near future regardless, but my understanding is that heparinization is independent from our current reversal methods and would be achieved even if someone had been given pcc/ffp. I can’t see myself holding reversal on these patient’s just because they may require heparinization in the future, I want to limit bleeding now and they can introduce more bleeding when the patient is in the OR.
I agree with Sean’s point about the medicolegal segment – highly relevant to our daily practice! Frequently we see obese pts who are requiring multiple rounds of sedating meds, and they are frequently in the hallway off a monitor. Although I’d like to think we would notice if someone was turning cyanotic, I think this part highlights the importance of having pulse ox on for pts at risk for respiratory depression (eg this type of pt, the post-narcan pt, etc).
One of the most interesting segments this month was the part about marijuana. Although I was nearly driven insane by their sound gimmicks, identifying marijuana as a risk factor for ACS//CAD fascinated me. I have also thought of marijuana as having the opposite of adrenergic effects, and was surprised to learn that it may be similar to cocaine in the acute setting. The Equal Access piece was very important in my opinion. I like the idea of asking about partners’ gender in an open way (traditional in med school it’s always “Men, Women, or both?”), and this is something I have started to use in my daily practice. As always, I loved the rural medicine piece, and was helpful to hear about an exotic fish-hook removal; this was great because I have never actually removed a fish-hook and hearing about the possible worst case scenario was informative should i ever be faced with that!
August 2019 EMRAP
1) 3 things I learned:
– dropped gallstones can cause post-CCY complications and are becoming more common now that most CCY’s are laparoscopic. They can cause fistulas, and even lead to infertility in women, so important to consider.
– On the pedi intubation segment, I liked the tips about marking your tube ahead of time to avoid going in too deep, and to consider the amount of air you’re putting in the cuff (start at 1-3cc)
– For infant botulism, fatigable pupils are a sign of botulism. Also, construction around the infant’s house can stir up botulism spores – definitely something I never considered before.
2) Areas of practice I’ll change:
– The medicolegal briefs case w/back pain scared me. Lessons I’ll apply from this: always give extra consideration when giving IM and IV opiates and benzo’s together, and if someone (RN, tech, family member, other provider) tells me I should check on my patient, I will not ignore it.
– For the LGBTQ segment, I loved the script idea of asking “what genders are your partners?” and “who is with you today?” instead of the awkward “men/women/both” and “is this your mother?” “No, my wife…” oops. I’ve already started using these new scripts in my practice.
3) Too “bleeding edge”
– The marijuana segment was interesting, but I’m not quite ready to add marijuana smoking as a risk factor in my Heart score assessment until there is more evidence.
– I still don’t think I’ll be starting out all of my encounters with “what pronouns do you prefer?” for every single patient. It’s a little too awkward to ask most people this, although I will continue to ask it to anyone for whom it may be relevant and will start widening the patient population who I ask this question.
1) The segment on DOACs was interesting. I definitely didn’t know that bleeding risk is increased in patients on warfarin with renal insufficiency. Overall, that segment was another reminder to consider renal function when dosing medications or evaluating a patient’s home medications in the setting of a change in renal function. A second thing I learned about was “dropped gallstones”; in typical EM:RAP fashion there was another thing that I was never the slightest bit aware of. A third thing that I found interesting was about giving tetanus immunoglobulin to those who are unvaccinated or immunosuppressed such as patients with HIV.
2) There were a number of things from this episode that might change my practice moving forward. From the previous question, I’ll be more likely (if I remember) to check CDC guidance on tetanus prophylaxis in our patients with poorly-controlled HIV. Similarly, I’ll be sure to thing about renal function when prescribing or continuing anticoagulants in the ED. I like the scripted phrases in the segment on LGBTQ patients and taking a more open-ended sexual history. I especially like the “what do you do to prevent STIs and pregnancy” phrase because it seems less judgemental and immediately conveys to the patient why that question is being asked. Based on the back pain case, I’ll definitely be more cognizant of patients requiring more than one category, or multiple doses, of sedating medications. We have a number of “attending only” cases and others with patients in hallways where we are routinely accepting high levels of risk with our medical management.
3) As thought-provoking as Dr. Weingart is, I feel like many of his practices are not ready for prime time. His reasons for not reversing anti-coagulation in dissection are logically sound, but at the end of the day the surgeons and the inpatient teams are the ones who manage these patients and shoulder the burden of the outcomes, so any policy decisions should be made with their input and blessing.
1. Three things learned
(1) I have always thought CT could definitively diagnose pneumothorax. The case presented showing CT may be equivocal in cases where patients have large blebs from COPD was very informative, and I appreciated the use of bedside US to help support the clinical impression that there was, in fact, no pneumothorax. The risk-benefit evaluation of placing a chest tube in a patient with COPD, known large blebs, and a question of pneumothorax who is showing clinical improvement was very helpful and cautionary.
(2) I have considered slipped gallstones in my differential for RUQ pain after cholecystectomy. The segment, “Mystery RUQ Pain Case” has taught me to include slipped gallstones in the differential for abdominal pain beyond the RUQ. I did not know that the stones could slip into the peritoneum and cause pathology as diverse as colocutaenous fistulas, colovesicuar fistulas, and even pelvic pain and infertility in female patients. Furthermore, it was important to learn that these stones may be radio-opaque – limiting the sensitivity of CT and possibly requiring MRI for diagnosis.
(3) Lastly, I enjoyed this month’s review of infantile botulism in the segment, “Pediatric Pearls – Floppy Baby.” It is important to remember that honey is NOT the most common cause of infantile botulism. In turn, exposure to spores from soil, such as that stirred up by construction work, IS the most common cause. We need to ask about possible soil/spore exposures during the interview. The presence of fatiguable pupillary reflexes is a very helpful clinical pearl for diagnosis.
2. Change to practice
Since listening to the segment “Equal Access for All: LGBTQ,” I have changed my practice by asking patients “What genders are your partner(s)?” rather than “Are you sexually active with men, women, or both?” as I collect the sexual history. I found this segment offered excellent examples of how scripting can improve our history gathering, break down assumptions and biases embedded in everyday language, and further cultivate an environment that feels inclusive for gender and sexual minorities.
3. “Bleeding edge”
There were not any segments or content in this month’s EMRAP that I felt were too “bleeding edge” or controversial for clinical practice at BMC. I think the piece about whether or not to reverse AC in patients with aortic dissection speaks to the importance of considering the major complications of dissection and discussing the management plan with our surgical colleagues as soon as possible.