EM:RAP and AIR Infectious Disease (Nov 2019)
AIR: https://www.aliemu.com/courses/capsules-infectious-diseases-1/
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/emrap20198/november/
When you have finished listening to the podcast, answer the following questions:
1. Please list three things you learned from this podcast that you were not aware of before.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
3. 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?
2 comments
Things I learned and how they’ll change my practice:
The electrical injuries segment was very helpful. This is not something we see often and it was great to reinforce several med school teachings (AC current is much more dangerous given muscle tetany and arrhythmias). Rhabdo seems like an obvious complication of electrical injury, however, stressing the risk of compartment syndrome was important, and particularly that the compartments may be completely separate from where the contact thermal injury is seen, so fasciotomies have to be performed instead of escharotomies of the burned area.
The segment on Amish communities was interesting and despite never having treated an Amish patient, I think some of the lessons overlap with BMC’s population as well. For one, many of our patients are skeptical of doctors and spending more time speaking with them and listening to their concerns may result in much higher adherence rates (although I would say we don’t have this opportunity with our current boarding situation). While many Amish do not use electricity, we often have to think about how we can accommodate homeless populations that don’t have access to a refrigerator or even reliable food supplies.
I recently had a case of a patient with possible Guillan Barre Syndrome that we intubated with rocuronium. We had a prolonged discussion with the neurology team about rocuronium and how they now did not have a neuro exam for an hour. At this time, no treatment change would have been guided by a neuro exam, so we did not use Sugammadex, but I can see how that would be useful occasionally. However, Dr Strayer really hits home that sugammadex is rarely of use and particularly should never be used in the case of can’t intubate, can’t ventilate. As someone who has never performed a cric, I think this podcast drives home the importance of not hesitating and proceeding to cric and not to second guess this daunting task now we have some newer “rescue” medications.
Too cutting edge for BMC:
ATLS – recommending needle thoracostomy along the 4/5th intercostal space – unless we stock longer needles designed for this purpose, I think we will continue to use finger thoracostomy liberally, particularly in trauma patients. (But also I’d love to get some 3 inch midlines to use instead of USIVs).
Syncope – much of this podcast discussed how 8-12 hrs in an ER without arrhythmia or obvious cause of syncope pretty much guarantees a hospital admission won’t find a cause. With all of the recent boarding, it would be great to start to establish chest pain and syncope protocols that are standardized in the ER so we can start discharging patients with uneventful ER boarding stays – leaving our obs unit open to patients with ongoing active treatments (since much of syncope/CP is simply observation).
Let’s get a 3d printer for the sim lab! It would be incredible to be able to 3d print cric models and other adjuncts to our already awesome sim lab. In general, I think we could have more opportunities to practice procedures we don’t do often (cric, lateral canthotomy, trach changes, transvenous pacing, pericardiocentesis, shoulder dystocia delivery, resuscitative hysterotomy) perhaps on a twice a year schedule.
1. Before this episode, I wasn’t aware that there was a reversal agent for rocuronium (sugammadex). If the place where I work has this, I would feel even more comfortable using rocuronium routinely, especially at higher doses to give similar onset characteristics to succinylcholine. I have heard of BRASH syndrome before, but this month’s episode had a great segment for review. I hadn’t thought of using isotonic bicarbonate for resuscitation, but I will keep that in mind should I run across this in the future. The second lightning strike segment was also very interesting. I had never heard of the pass-over effect (most of the lightning traveling around and not through people) or the brainstem stunning piece. Very interesting!
2. Since listening to this episode several months ago, I have already started sending home more syncope patients – typically those with diaphoresis or prodromal symptoms consistent with vasovagal syncope. It’s helpful to know that admission doesn’t reveal additional information to make a definitive diagnosis in most cases, so I can feel more comfortable just admitting those at risk for dysrhythmias or other concerning etiologies.
3. I don’t think that the HINTS exam is yet appropriate in my mind to preclude imaging or neurology consult. The excellent test characteristics were obtained through highly experienced neuroophthalmologists. I also don’t think sending home all those neutropenic fever patients is realistic at this point as this is an interdisciplinary decision that has to be made, and the few cases I’ve had over the years have shown me that Hem Onc really wants these patients admitted.