HEART Pathway

Valentines card (photo Wikimedia Commons)

Valentines Day is this week on February 14th. What better time to review the HEART Pathway for your patients with chest pain.

(Photo PubMed Commons)

Check out the podcast or pdf on how one community hospital incorporated it into their electronic medical record (EMR) in the February EMRAP podcast: HEART in EMR; by Rob Orman MD and Peter Smulowitz MD. Don’t use EMR at your facility…leave a comment and tell your colleagues how you would use it in your practice or at your facility.

Who knew? In 1835, 60,000 Valentine cards were sent by post in Britain, despite postage being expensive. (Wikipedia)

 

 

Push the Pause Button

(Wikimedia Commons image)

Several years ago my team and I resuscitated a two-year-old child with fulminant meningococcemia during a night shift in a small community hospital. It was only my second case in 25 years of practice, but despite providing all the right lifelines and transfer to a tertiary care facility with a pediatric ICU…I knew the child would die.

We carried on with our duties long after the helicopter departed…steadfast yet each of us enveloped in our own sadness. It wasn’t until weeks later during the “debriefing” meant to cleanse our hearts and minds of the tragedy did we dare face the death together as a team.

I can tell you from experience this is not the way to approach a death of this magnitude…or any death. Take a short listen or read about initiating “The Pause” after a death no matter where you practice by listening to: The Pause by Reuben Strayer MD on the February EMRAP cme.

Who knew? Ever wonder where those computer symbols originated? According to Gizmodo, the pause symbol is based on a musical notation, the caesura, which indicates a-wait for it-pause.

 

 

Hyperbilirubinemia: Mellow Yellow Isn’t Just a 1960’s Song

Phototherapy for neonatal jaundice. (photo courtesy Wikicommons)

Hyperbilirubinemia: one of the most common problems seen in term newborns and warrants a periodic review to refresh our knowledge base. Consider this case: A well-appearing infant presents and is jaundiced. The baby has a cephalohematoma and is breast feeding. Everything else is fine. The child is eating well and urinating. Do you still need to send labs?

Take a listen to the MP3 podcast or read the PDF in the January EMRAP podcast: Hyperbilirubinemia by Rob Orman MD and Tim Horeczko MD.

 

Who Knew? Jaundice was observed for centuries but the earliest medical literature was by Jean Baptiste Thimotee Baumes (Baumes, J. 1806). This description was published as a chapter in a book entitled: Traite de L’amaigrissemwnt des enfans. Christian Schmorl in Dresden was the first to coin the term “Kernicterus” in 1904.

 

 

Pneumonia Reboot: Admit or Discharge Decisions

CXR of a 37-yr-old male with pneumonia and abscess. (Photo from Wikicommons).

CT scan of the chest showing bilateral pneumonia with abscesses, effusions, and caverns. 37 year old male. (Photo from Wikicommons)

The case as presented in the January 2018 EMRAP files:

A 73-year-old male with a history of hypertension, hyperlipidemia and aortic stenosis presented with cough, fever and sputum. He was mildly tachycardic but not tachypneic and was well-appearing. On lung exam, he had some focal wheezes in the left lower lobe. Swaminathan thought the patient had pneumonia. Chest x-ray confirmed a left lower lobe infiltrate.

Now what? What else do you need to know about this patient that impacts discharge planning. It’s flu season here in the USA, the ED and wards are filled with critical patients and beds are in high demand. Do you really need to admit this patient? Tie up a bed? Expose him to hospital-acquired infections?

Listen to the January EMRAP Introduction podcast or read the PDF by Rob Orman MD and Anand Swaminathan MD to find guidance and opinions.

Who knew? The CURB-65 and the PORT Score can help you make these difficult decisions.

Osteomyelitis: The Diabetic’s Skeleton in the Closet

Femur. Osteomyelitis. From ancient cemetery, Chicama Valley, Peru ; (Photo courtesy WikiCommons)

X-ray osteomyelitis 1st metatarsal joint (photo courtesy WikiCommons)

Do you admit all your diabetic patients with suspected osteomyelitis? Do you need to?

Is it acute or chronic?

Do you need to culture all diabetic foot ulcers?

What two entities will help identify patients at risk for osteomyelitis? The answer may surprise you.

Download from CMES the podcast or PDF for the December EM:RAP Diabetic Foot Ulcers by Matthew DeLaney MD and Charles Khoury MD and share your experiences or recommendations by leaving a comment.

 

Who Knew? Evidence for osteomyelitis found in fossil records are studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis.

Life Threatening Bleeds in Oral Anticoagulated Patients

Noval Oral Anticoagulant (NOAC) medications. Travelers like the convenience because they don’t need monthly blood tests. It also means they show up in your emergency departments and clinics from all over the world with minor and major bleeds. How do you know what reversal agent to give or even if there is one? Perhaps they can’t recall the name or a friend is watching their belongings at the hotel.

Check out the December Annuals of Emergency Medicine podcast: Reversal of NOACs by Jessica Mason MD, Andy Grock MD and Annahieta Kalantari DO. The simple answer may surprise you.

Who knew? Hirudin extracts from the medicinal leeches were first used for parenteral anticoagulation in the clinic in 1909, but their use was limited due to adverse effects and difficulties in achieving highly purified extracts. Published by NCBI PubMed 2012 Jun 1;9(2):83-104.

 

Standard Oxygen Therapy Ignites Controversy

Does oxygen therapy make a difference in heart attack patients?The European Society of Cardiology, news release, Aug. 28, 2017 cited this Swedish study which found no difference in patient outcomes.

EM:RAP has up-to-date information about using oxygen therapy in the acute setting. So hold your breath and check out these podcasts:

Paper Chase 2: The Oxygen Middle Path by Sanjay Arora MD and Michael Menchine MD

Introduction: Flush Rate Oxygenation by Rob Orman MD and Anand Swaminathan MD

Did you know?  Oxygen was discovered independently by Carl Wilhelm Scheele, in Uppsala, Sweden in 1773 or earlier, and Joseph Priestley in Wiltshire, England in 1774, but Priestley is often given priority because his work was published first. Priestly fled to America in 1793 to escape political persecution. The Joseph Priestley museum is in my hometown Northumberland, Pennsylvania USA…I’ve never been there.

 

 

Fishing for Anaphylaxis Treatment

First up…a really bad pun to get your creative energy flowing: What was the cause of the tech-guru’s most recent seafood reaction?
A new shell-phone!

Log into CMES and scratch up the June 2017 EM:RAP podcast called The Case of the Funky Fish by Stuart Swadron MD and Billy Mallon MD for up-to-date information on the treatment of acute anaphylaxis.

Now challenge your colleagues with a similar case. Which drug do you reach for first? Is epinephrine given in the arm or thigh or doesn’t it matter? Do they use both H1 and H2 blockers and where is the evidence these work? Have steroids even been scientifically proven to help in acute allergic reactions?

The life of your patient may depend on your knowledge of these questions and how quickly you start treatment…hopefully faster than edema swells their airway shut.

Read more

Mind the Migraines

A shift would not be complete without one headache patient. I would wager that is the same wherever you practice because I treated migraine headache patients from remote Himalayan villages to tropical islands in the Caribbean.

The worrisome causes of headaches such as pregnant + hypertension + headache; new onset after age 50; headache + fever, headache + altered mental status; abrupt onset headache; and headache + painful red eye to name a few should prompt investigation and immediate treatment.

But for the treatment of one of the most common types of headache, the migraine, check out the EM:RAP August Pharmacology Rounds: What Works for Acute Migraine? by Rob Orman MD and Bryan Hayes PharmD.

Migraines have been recorded in medical history for a long time, the first found documentation in the Ebers Papyrus written around 1500 BCE. For you language buffs the word migraine is derived from the Greek word hemikrania. This term was corrupted into hemigranea and the common word comes from the French translation, migraine.

EM:RAP – Super Suture Lectures

Last October 2016, I gave a suture lecture at Kathmandu Model Hospital, Grande International Hospital and both CIWEC hospitals in Kathmandu and Pokhara. Although doctors approach suturing in a myriad of ways based on education, preference, and experience, the one thing we agreed on was…reviewing the basics and yearly updates are helpful.

CMES participants can download the excellent suture lecture from the March and April 2017 EM:RAP archives. Share your knowledge and learn from your colleagues by giving a lecture at your institution on wound repair.

March:

Wound Repair Part 1 – Wound Prep

Brian Lin, MD and Zach Shinar, MD
April:

Wound Repair Part 2 – Eversion and Simple Interrupted

Jonathan Kantor, MD, Zach Shinar, MD, and Brian Lin, MD
1 2 3 4