Podcasts about ercast

In this insightful conversation, I speak with Dr. Rob Orman, emergency physician turned physician coach, about the urgent challenges many clinicians face—including burnout, incivility, and a lack of sustainability in traditional healthcare roles. Rob is the creator and host of The Stimulus Podcast and leads Orman Physician Coaching. He holds extensive expertise as a medical educator, is a multiple award-winning speaker with a deep background in communication. He served as chief editor of EM:RAP, created the Stimulus and ERcast podcasts, and for nearly a decade hosted Essentials of Emergency Medicine, the largest single-track emergency medicine conference in the world.  The discussion touches on the structure of physician jobs, how coaching can shift individual mindsets and institutional culture, and how moving from rumination to action can be transformative. Recommended readings and tangible strategies round out this thoughtful episode for anyone rethinking their path in medicine. Key takeaways: —Recalibration is essential for physicians confronting burnout and stress. —Incivility in healthcare environments undermines physician well-being. —Coaching offers sustainable solutions for personal and professional growth. —Coaching can improve not just individual outcomes but also hospital culture. —The traditional structure of medical roles often overlooks clinician health. For further reading: —What Got You Here Won't Get you There Marshall Goldsmith —A Guide to the Good Life William Irvine —The Advice Trap Robert Bungay Stanier Book a  Coaching Discovery Session with Rob If you enjoy the show, please leave a ⭐⭐⭐⭐⭐ rating on Apple or a

Dr. Orman spent 21 years working in clinical community emergency medicine. In the first 10 years of his practice, he experienced three severe burnouts. Without much guidance, he thought the solution was to work harder - grit it out. Soon after his third major bout of burnout, Dr. Orman realized that his current way of life wasn't sustainable. So, he switched gears to work in medical education, and that became a salvation for him, giving him a new purpose. This led him to start his podcast, Stimulus, and spend a year getting his certification from a coaching academy. Dr. Orman is now a certified executive coach, and he dedicates his time to helping physicians develop strategies to live and work with intent, creatively solve problems, and practice self-compassion.Tune in to this episode of the Prosperous Doc® to hear our host Shane Tenny, CFP®, chat with Dr. Orman about the true meaning of grit and how physicians can still have it while being gentler with themselves.

28 years ago, the die was cast for how emergency department encounters were documented.  Since then, we've had note bloat, click fatigue, and too much attention placed on things that really didn't matter. All of that is slated to change in 2023 with dramatic new documentation guidelines (that today's guest calls ‘refreshing') are implemented. When was the last time you heard the word ‘refreshing' used when it came to charting? And a massive thank you and hat tip to my friend Matt DeLaney who now runs ERcast - he was the first to alert us to these guidelines and interviewed Jason when they were first announced.    Episode Sponsor: Ivy Clinicians. Curious if there's a better clinical opportunity out there? Ivy is the simplest way for physicians, PAs, and nurse practitioners to match with jobs they love. With Ivy, you can find all 5,549 emergency departments, filter by your preferences, and connect securely with the right employers. All for free. Guest bio: Jason Adler, MD is  a clinical assistant professor of emergency medicine at the  University of Maryland where he is also the director of compliance and reimbursement. He is also the vice  president of acute care solutions at LogixHealth. Mentioned in this episode: The Awake and Aware Physician conference sponsored by Wild Health. Jan 13-15 Sedona Arizona. Use the code CONSCIOUSPHYSICIAN for 15% off (that's 15% off the whole package – lodging, meals, the course) Interested in one-on-one coaching? Learn more at roborman.com To support the show - visit our Patreon site and help keep the wind in the sails. For full show notes visit our podcast page We Discuss: History and physical documentation are now at your discretion; Heavy value is placed on cognitive work and medical decision making; History from a non-patient source is valued in these guidelines; Ordering a test is equally valued as not ordering a test; Consideration of escalation or deescalation of care; In addition to documenting your shared-decision making conversations, your MDM should include; Population health - Stable means something different when it comes to documentation; Social determinants of health; There is a heightened emphasis of independent interpretations of separately billable procedures (EKGs, X-ray, CT, U/S); Jason's take home points; And More.

28 years ago, the die was cast for how emergency department encounters were documented.  Since then, we've had note bloat, click fatigue, and too much attention placed on things that really didn't matter. All of that is slated to change in 2023 with dramatic new documentation guidelines (that today's guest calls ‘refreshing') are implemented. When was the last time you heard the word ‘refreshing' used when it came to charting? And a massive thank you and hat tip to my friend Matt DeLaney who now runs ERcast - he was the first to alert us to these guidelines and interviewed Jason when they were first announced.    Episode Sponsor: Ivy Clinicians. Curious if there's a better clinical opportunity out there? Ivy is the simplest way for physicians, PAs, and nurse practitioners to match with jobs they love. With Ivy, you can find all 5,549 emergency departments, filter by your preferences, and connect securely with the right employers. All for free. Guest bio: Jason Adler, MD is  a clinical assistant professor of emergency medicine at the  University of Maryland where he is also the director of compliance and reimbursement. He is also the vice  president of acute care solutions at LogixHealth. Mentioned in this episode: The Awake and Aware Physician conference sponsored by Wild Health. Jan 13-15 Sedona Arizona. Use the code CONSCIOUSPHYSICIAN for 15% off (that's 15% off the whole package – lodging, meals, the course) Interested in one-on-one coaching? Learn more at roborman.com To support the show - visit our Patreon site and help keep the wind in the sails. For full show notes visit our podcast page We Discuss: History and physical documentation are now at your discretion; Heavy value is placed on cognitive work and medical decision making; History from a non-patient source is valued in these guidelines; Ordering a test is equally valued as not ordering a test; Consideration of escalation or deescalation of care; In addition to documenting your shared-decision making conversations, your MDM should include; Population health - Stable means something different when it comes to documentation; Social determinants of health; There is a heightened emphasis of independent interpretations of separately billable procedures (EKGs, X-ray, CT, U/S); Jason's take home points; And More.

There is no doubt that handing over care of a patient to another clinician is potentially fraught with peril. After all, it's in the transitional moments when error is most likely to occur. But there's a balance to strike here because there are also myriad upsides to signouts for both the patient and clinician. In this episode, Mike Weinstock, MD breaks down the arguments in favor of signouts, how to do them well, the big fat hairy signout pitfall,  and why signouts might just be a key ingredient to career longevity and patient safety. Guest Bio: Mike Weinstock, MD  is Professor of Emergency Medicine, adjunct in the Department of Emergency Medicine of The Ohio State University's College of Medicine, and director of research and CME at the Adena Hospital. He has lectured nationally and internationally on medical topics and patient safety issues and is the executive editor for UC RAP, contributed to ERcast and Risk Management Monthly, and has published original research in JAMA IM and Annals of Emergency Medicine. He is the author of the Bouncebacks! series of books,and How'd it Go?. Mike has practiced medicine nationally and internationally including volunteer work in Papua New Guinea, Nepal, and the West Indies. We discuss: How the key to protecting yourself medico-legally is having your primary concern be about patient safety and then documenting such that the chart reflects good medical care [01:50]; Principles of medically defensible charting [05:00]; Rob's chest pain template medical decision-making (MDM) [08:30]; The importance of remembering that one-directional rules (like PERC for PE) do not obligate you to do a workup if a patient fails the rule [12:00]; Why handing off a patient to the incoming doctor when your shift is over may contribute to a successful career as an emergency physician [13:00]; Whether your level of busy-ness during an ED shift is seen as an extenuating circumstance by a defense or plaintiff's attorney [18:45]; An argument for always reviewing nursing/paramedic notes (and documenting that you did it) and trying to greet EMS when they arrive with a new patient [24:45]; Mike's opinion of the ideal sign-out culture [32:00];  Some doctors are not comfortable signing out patients, but they take a risk in their career longevity by not doing so [35:30]; Why sign-outs need to have constraints [39:25]; More.   For previous episodes, detailed show notes, or to sign up for our newsletter: https://roborman.com/category/stimulus/ This podcast streams free on iTunes, Spotify, and Stitcher. Interested in one-on-one coaching? https://roborman.com/ Follow Rob:  Twitter, Facebook, and Youtube.

There is no doubt that handing over care of a patient to another clinician is potentially fraught with peril. After all, it's in the transitional moments when error is most likely to occur. But there's a balance to strike here because there are also myriad upsides to signouts for both the patient and clinician. In this episode, Mike Weinstock, MD breaks down the arguments in favor of signouts, how to do them well, the big fat hairy signout pitfall,  and why signouts might just be a key ingredient to career longevity and patient safety. Guest Bio: Mike Weinstock, MD  is Professor of Emergency Medicine, adjunct in the Department of Emergency Medicine of The Ohio State University's College of Medicine, and director of research and CME at the Adena Hospital. He has lectured nationally and internationally on medical topics and patient safety issues and is the executive editor for UC RAP, contributed to ERcast and Risk Management Monthly, and has published original research in JAMA IM and Annals of Emergency Medicine. He is the author of the Bouncebacks! series of books,and How'd it Go?. Mike has practiced medicine nationally and internationally including volunteer work in Papua New Guinea, Nepal, and the West Indies. We discuss: How the key to protecting yourself medico-legally is having your primary concern be about patient safety and then documenting such that the chart reflects good medical care [01:50]; Principles of medically defensible charting [05:00]; Rob's chest pain template medical decision-making (MDM) [08:30]; The importance of remembering that one-directional rules (like PERC for PE) do not obligate you to do a workup if a patient fails the rule [12:00]; Why handing off a patient to the incoming doctor when your shift is over may contribute to a successful career as an emergency physician [13:00]; Whether your level of busy-ness during an ED shift is seen as an extenuating circumstance by a defense or plaintiff's attorney [18:45]; An argument for always reviewing nursing/paramedic notes (and documenting that you did it) and trying to greet EMS when they arrive with a new patient [24:45]; Mike's opinion of the ideal sign-out culture [32:00];  Some doctors are not comfortable signing out patients, but they take a risk in their career longevity by not doing so [35:30]; Why sign-outs need to have constraints [39:25]; More.   For previous episodes, detailed show notes, or to sign up for our newsletter: https://roborman.com/category/stimulus/ This podcast streams free on iTunes, Spotify, and Stitcher. Interested in one-on-one coaching? https://roborman.com/ Follow Rob:  Twitter, Facebook, and Youtube.

 As emergency physicians, we experience a great deal of success, and failure, in our journeys. What can failure and success teach us, and how can we best use these to grow? Today on the emDocs podcast, Brit Long, MD (@long_brit) interviews Rob Orman (@emergencypdx), host of ERCast, the Stimulus Podcast, and Essentials of Emergency Medicine. The first part looked at Rob's perspectives on failure and how to learn from it. Today we look at success in EM and life. To continue to make this a worthwhile podcast for you to listen to, we appreciate any feedback and comments you may have for us. Please let us know!Subscribe to the podcast on one of the many platforms below:Apple iTunesSpotifyGoogle Play

As emergency physicians, we experience a great deal of success, and failure, in our journeys. What can failure and success teach us, and how can we best use these to grow? Today on the emDocs podcast, Brit Long, MD (@long_brit) interviews Rob Orman (@emergencypdx), host of ERCast, the Stimulus Podcast, and Essentials of Emergency Medicine. This first part will look at Rob's perspectives on failure and how to learn from it. In the second part, we will cover success in EM and life. To continue to make this a worthwhile podcast for you to listen to, we appreciate any feedback and comments you may have for us. Please let us know!Subscribe to the podcast on one of the many platforms below:Apple iTunesSpotifyGoogle Play

The COVID vaccines are upon us! In this episode we disambiguate COVID vax side effects and the historical effects of acetaminophen and sleep on vaccine antibody response.  Listen on: iTunes Spotify Stitcher We Discuss: Listener questions about ERcast and how an mRNA vaccine works [0:00:30]; COVID mutations in Europe may increase transmissibility [00:04:40]; Recently published side effects and adverse reactions of Pfizer COVID vaccine [00:06:05] Impact of acetaminophen and ibuprofen on vaccine antibody response [00:10:13]; How sleep impacts vaccine antibody response [00:16:19].   For complete and detailed show notes, previous episodes, or to sign up for our newsletter: https://www.stimuluspodcast.com/ If you like what you hear on Stimulus and use Apple/iTunes as your podcatcher, please consider leaving a review of the show. I read all the reviews and, more importantly, so do potential guests. Thanks in advance! Interested in sponsoring this podcast? Connect with us here Follow Rob:Twitter: https://twitter.com/emergencypdx Facebook: https://www.facebook.com/stimuluswithrobormanmd Youtube: https://www.youtube.com/c/emergencypdx

The COVID vaccines are upon us! In this episode we disambiguate COVID vax side effects and the historical effects of acetaminophen and sleep on vaccine antibody response.  Listen on: iTunes Spotify Stitcher We Discuss: Listener questions about ERcast and how an mRNA vaccine works [0:00:30]; COVID mutations in Europe may increase transmissibility [00:04:40]; Recently published side effects and adverse reactions of Pfizer COVID vaccine [00:06:05] Impact of acetaminophen and ibuprofen on vaccine antibody response [00:10:13]; How sleep impacts vaccine antibody response [00:16:19].   For complete and detailed show notes, previous episodes, or to sign up for our newsletter: https://www.stimuluspodcast.com/ If you like what you hear on Stimulus and use Apple/iTunes as your podcatcher, please consider leaving a review of the show. I read all the reviews and, more importantly, so do potential guests. Thanks in advance! Interested in sponsoring this podcast? Connect with us here Follow Rob:Twitter: https://twitter.com/emergencypdx Facebook: https://www.facebook.com/stimuluswithrobormanmd Youtube: https://www.youtube.com/c/emergencypdx

In the swan song of ERcast Lite, we speak with Scott Weingart about the truths, misunderstandings, and physiology of ECMO. To subscribe to ERcast and get 2.5 hours of high yield monthly content, CME, and all sorts of goodies, use the code 'bacon' for a 3 month free trial. https://www.hippoed.com/em/ercast/   Pearls: VV ECMO takes over lung function and is used for those with severe lung disease (ie. ARDS, pneumonia, severe asthma). VA ECMO takes over the heart and lung. Ideal candidates are patients with massive PE or cardiogenic shock. Intubated patients who you can’t oxygenate despite rapidly escalating PEEP and a high FiO2 should be considered for VV ECMO.     There are 2 primary types of extracorporeal membrane oxygenation (ECMO):  veno-venous (VV) and veno-arterial (VA). VV ECMO takes over lung function. It drains blood from the IVC or SVC, sends it through a pump which delivers it to an oxygenator (a membrane which allows the influx of oxygen and removes CO2), and then pumps the oxygenated blood back into the right heart system (returning it to the IVC or SVC).   Useful for those with severe lung disease but decent heart function. Examples:  pneumonia, ARDS, severe asthma with CO2 retention, immunologic lung diseases, cystic fibrosis awaiting lung transplant Limited by its complications, cost, and logistical catastrophes. VA ECMO takes over lung AND heart function. It drains blood from the IVC/SVC, pumps it out and sends it to an oxygenator, and then returns the blood retrograde up the aorta so it can perfuse the abdominal viscera, brain, and possibly even the heart.   For patients with cardiogenic shock or massive PE. Does not yield as much benefit for patients with septic shock or other vasodilatory states (unless they had a sepsis-induced cardiomyopathy). Shares the same limitations as VV ECMO, with the addition that the physiology induced by the VA ECMO itself can be deleterious.   Which patients might benefit from transfer to an ECMO center? The threshold for transfer depends in part on the capabilities at your institution for advanced ventilatory modalities (ie. airway pressure release ventilation, proning patients, nitric oxide).  A large percentage of patients transferred for ECMO never end up receiving or needing it. However, they still greatly benefit from moving to a facility that has the ability to provide other nuanced critical care options. In general, transfer young patients who are on very high vent settings and not getting better.  At a community hospital with few vent resources, these patients should be transferred within hours.  At bigger institutions, transfer within 48 hours. Often people wait too long (5-7 days) to initiate the transfer.     Use the ARDSnet Mechanical Ventilation Protocol and Murray Score to help decide if a patient would be a good VV ECMO candidate.  The ARDSnet protocol is evidence-based and communicates where the patient is on their vent settings. It gives receiving centers a clean way to evaluate patients for potential transfer. Patients should be

COVID-19 causes STEMI’s, arrhythmias and myocarditis?!? Emergency medicine and cardiology guru Amal Mattu, MD chats with Mizuho Morrison, DO on the cardiovascular effects of COVID-19. They discuss: the known pathophysiology of how viral infections affect the heart; Review the new consensus statement from the Society of Cardiovascular Angiography and interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) on how to manage STEMIs; and lastly discuss how cardiac arrest management differs in this COVID era.      Promo code for 3 month trial of ERcast in intro segment Hippo education COVID resource site: Link   References:  Mahjid, M. Payam, S. et al. Potential Effects of Coronaviruses on the Cardiovascular System: A Review [published online ahead of print, 2020 Mar 27]. JAMA Cardiol. PMID 32219363 Mahmud E, Dauerman HL, et al.  Management of Acute Myocardial Infarction During the COVID-19 Pandemic,CONSENSUS STATEMENT from the Society of cardiovascular angiography and interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). Journal of the American College of Cardiology (2020), doi https://doi.org/10.1016/j.jacc.2020.04.039. PMID:32330544 Edelson D, Sasson C. et al. Interim Guidance for Basic and Advanced Life support in Adults, Children and Neonates with suspected or confirmed COVID-19. Circulation AHA April 2020. PMID: 32270695 Stefanini GG, Azzolini E, et al. Critical Organizational Issues for Cardiologists in the COVID-19 Outbreak: A Frontline Experience From Milan, Italy [published online ahead of print, 2020 Mar 24]. Circulation 2020. PMID: 32207994

A critical care crash course with Mizuho Morrison and Scott Weingart. We discuss: Big picture and escalation of care Step by step approach to respiratory support for the 'happy hypoxemic' COVID intubation Ventilator settings and troubleshooting Society of Critical Care guidelines IV Fluids, vasopressors, steroids, anticoagulation Complete show notes: Click Here Complete show notes PDF: Click Here Hippo Education COVID resource site: https://covid.hippoed.com Learn more about ERcast: https://www.hippoed.com/em/ercast/

Hematologist Tom Deloughery gives a primer on COVID-19 cytokine storm, d-dimer, DIC that leans toward thrombus, why some clots break through heparin, utility of low molecular weight heparin, and using TPA for ARDS (don’t get too excited on that one quite yet).   We discuss: Great advice from Loren Rauch: we should reframe social distancing and instead think of it as physical distancing and social connectedness [0:00]; Cytokine storm and why it happens in COVID-19 [3:30}; How DIC and prothrombotic state are connected to cytokine storm [6:12]; Reasons why some COVID-19 patients have elevated D-dimer [8:43]; The association between elevated D-dimer and increased mortality [9:08]; The significance of an elevated LDH [14:47]; Why a standard approach to using unfractionated heparin might not work in COVID-19 thromboses [15:27]; Anti-Xa levels and why they might be more advantageous than following PTT [15:58] Tom’s preference for low molecular weight heparin  in COVID-related DVT and strategies for management if there are breakthrough clots [16:54]; When to change from therapeutic to prophylactic anticoagulation [22:32]; COVID-19 effects on lymphocytes and hemoglobin [23:20]; Elevated D-dimer summary [26;:47]; Case report of 3 patients given TPA for severe ARDS  [28:01] For a ton of other high yield info, check out the Hippo Education COVID-19 Resource Site Learn more about ERcast: https://www.hippoed.com/em/ercast/   References and other stuff mentioned in this episode: PulmCrit analysis of elevated D-dimer Link REBEL EM thrombosis page Link Cui S, et al. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost. April 2020. PMID: 32271988 Pulm crit wee on this paper Link Wang, J., et al. (2020), Tissue Plasminogen Activator (tPA) Treatment for COVID‐19 Associated Acute Respiratory Distress Syndrome (ARDS): A Case Series. J Thromb Haemost. Accepted Author Manuscript. PMID: 32267998. Zhou, Fei, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study." The Lancet (2020). PMID: 32171076

Kirkland, Washington was the first U.S. city with reports of a large-scale COVID-19 outbreak. In this special edition of ERcast, Dr. Patrick Reinfried, an emergency physician practicing at Kirkland’s Evergreen Hospital, gives a first hand account of what happened in his community, how his hospital has responded, and lessons learned.   In this episode: Difficult decisions that might not have been made before the outbreak Testing What factors go into deciding admission vs. discharge How to limit exposure to COVID patients and save PPE Organizing the emergency department with an area dedicated to fever and respiratory illness Patient flow Utility of BiPAP vs intubation Lab ordering X-rays Psychological impact. 

In today's episode, emergency physicians Amy Cho and Jason Adler break down novel ways to limit use of PPE while at the same time minimizing contact with potentially infected patients. We also talk about how government regulations have obstructed our ability to provide intelligent care but now those regulations are starting to relax, a few seconds on washing your gloves,  how do you respond when a COVID patient is coding (more of a question than an answer in this conversation), and what key moves for leadership that can make an impact.  There  are so many excellent resources currently regarding COVID-19 that, moving forward, we are only going to try and cover what we are not seeing or hearing anywhere else. There is a  link below to our newsletter which has some excellent resources that ERcast is using to stay current.  Links from this episdoe ERcast Newsletter with COVID resources  CMS Expands Telehealth: Link to CMS page with this info

Boa nooooite, plantonista. Hoje é dia de discutirmos uma lesão que é importante que todos os emergencistas conheçam. O episódio é sonorizado de forma especial, por isso peço que ouçam … Continue reading ERcast 10 – Episódio Especial: Qual lesão é essa?

Boa noite, plantonistas! Essa é a continuação do episódio 08 sobre máscara laríngea. Se você não ouviu o episódio 08, volte e ouça antes de ouvir esse. Espero que gostem!

Boa noite, plantonistas! Hoje o tema é um dos dispositivos mais importantes para abordagem da via aérea na emergência: a máscara laríngea. Indicações Dispositivo de resgate na via aérea falha(não … Continue reading ERcast 08 – Máscara Laríngea, o início…

In this 10th anniversary special, GFOP Josh Russell interviews Rob and digs deep into... Failing at work Finding the right job (and being honest about the wrong one) Top Gun Origins of ERcast Why Rectal Foreign Bodies was the subject of episode one Advice for young doctors How failing a black belt test was a pivotal moment Guiding principles Memento Mori This pod contains absolutely no clinical medical education. There is no CME attached to it. 

Are we calling burnout by the right name? Some would say no, we should call it 'moral injury' because what we see happening in modern medical practice can be antithetical to our core values. In this episode, ZDoggMD is our guest as we examine moral injury, as well as dealing with the EHR, stress, universal health care, meditation, and  much more. 

Should we admit medical mistakes? Most risk managers (and med mal attorneys) might say no, but Dr. Peter Smulowitz says that’s the wrong thinking. Admitting errors can be good for patients and good for us.   Links mentioned in this episode Register for Essentials of EM. San Francisco May 21-23, 2020 Become a subscribing member of ERcast   Shownotes Pearls: The victims of our current risk-management strategy (which is to pretend it didn’t happen, and, if discovered, to deny and defend) are the patient, the provider, and the system.  Communication, Apology, and Resolution (CARe) programs have been developed to encourage providers to talk about adverse events and create a transparent process with the patients and families.    The status quo for the way we handle mistakes creates multiple victims, but no winners.  [00:40] When a mistake is made in a hospital, the common response is to pretend that it never happened. And then if it’s discovered, we’ve learned to deny and to defend, before beginning a prolonged process of resolution.  This adversarial process leads to a lost opportunity to learn from the mistake, on the individual and institutional level. It also prevents providing closure to the victim of the mistake. Our approach to managing adverse events often comes under the guise of risk management.  But perhaps we need to reframe these events from managing risk to managing patients. Who are the victims of our current  risk-management strategy?  The patient:  According to the Institute of Medicine, the liability system is the number one impediment to patient safety.  Further, when something bad happens and compensation is deserved, the patient receives 30 cents on the dollar.  The rest goes to administrative waste and legal fees. Oftentimes, the patient never even receives an answer when a major adverse event happens. The provider:  Providers spend much of their careers worrying about and trying to avoid lawsuits. And when lawsuits happen, there are significant impacts in terms of depression, substance abuse, and burnout. The whole system:  One study showed that we spend about $1.4 billion a year on defensive medicine. That is a significant impact on health care costs. It was the aftermath of an unfortunate case that sparked Smulowitz’ interest in this subject. It motivated him to try to make systems better so that others did not have to go through the same trauma. [03:40] Case A 24 year old man presented with thoracic back pain after lifting boxes.  An MRI was ordered due to a history of substance abuse and was read as normal.  In the ED, the patient had a sudden PEA arrest and died. The MRI was re-read as showing an aortic abnormality.   Smulowitz felt horrible after this case. He had zero confidence in himself, and he almost quit practicing medicine. The hospital’s response was not ideal.  Risk management advised that he only speak to a psychiatrist about the case.  He felt completely alone. He imagines the patient’s family must have felt terribly as well.  They couldn’t talk to anybody about what had happened. Even though the case settled, Smulowitz isn’t sure they ever truly got answers.  And they probably have no idea how badly he felt.  Smulowitz regrets that he didn’t have the chance to talk to the family and to apologize that such a horrible thing happened to their loved one.  The current practice of pretending that bad things don’t happen is absurd.  We’re going to make mistakes, and we practice in imperfect systems where bad things are going to happen to people despite our best efforts. The institutionalized isolation that we’re almost obliged to enter after an adverse event contributes to the second victim syndrome.  The patient is the first victim, and the healthcare provider, who is traumatized by the event, is the second. We are taught not to apologize after an adverse event. But is this good advice? [11:00] Many states have apology laws which protect you either partially or fully when you admit fault after an adverse event.  But Smulowitz believes these are almost useless in terms of their ability to protect from legal action. The laws are in place primarily to support and promote the apology process. Excerpt from an article about apology laws:     “Although physicians may feel the need to apologize after an adverse medical event, physicians’ gut instincts to apologize are often hampered by the fear that their statements will be used against them in court.  This fear is further solidified when their attorneys advise them to be careful not to admit fault or liability. This seemingly well thought out strategy to remain silent actually creates an unexpected paradox. Refusing to apologize can precipitate litigation to an even greater extent.  Consequently, the lack of an apology can dilute the doctor-patient relationship, hinder patient safety, and increase litigation.”    Communication is critical and an apology can be beneficial. It is the responsibility of the provider and the hospital to communicate with patients in the aftermath of an adverse event.  An apology is not an admission of fault. Apologies are beneficial to the physician as long as you’re not saying something crazy within the apology. Apologizing for something bad happening can be protective in the court of law because it makes physicians look like human beings. Communication, Apology, and Resolution (CARe) programs have been developed to bring providers out of the shadows, encouraging them to talk about adverse events and encouraging a transparent process with the patients and families. [13:05] Communication -- There should be early and ongoing communication in the aftermath of an adverse event. Apology -- There should be an apology when mistakes happen. Sample verbiage:  “It is so horrible that this bad event happened to you. We are devastated that this occurred. We are going to continue taking care of you/your loved one and our hospital is going to be carefully reviewing what just happened.  We’re going to get back to you with the results we find.” Resolution --  Make sure that patients receive just and timely compensation when bad things occur that are directly attributable to deviation from the standard of care.   Note that some patients/families do not desire financial compensation and just want explanations. Patients who receive financial compensation through CARe must sign a waiver saying they will not later file a lawsuit. But if the adverse event is not attributable to negligence or the lack of standard of care, there should be robust defense of the hospital, provider, or system. Providers should be supported if the event was outside of anybody else’s control. Institutionalizing this process is the only way to make it work, because you have to tie the communication and the apology piece to a true, just, and timely resolution. How would you apply the CAR process to this hypothetical scenario:  a young woman with a viable pregnancy is mistakenly given methotrexate (which was ordered for the patient with an ectopic in the room next to her)? First, the provider needs to communicate the mistake to the patient.  “You were given methotrexate and we don’t know the reason for it yet.  We also don’t know what the outcome will be for you. We’re going to continue to investigate what happened and we will continue to support you.” Second, the error should be shared with your institution’s designated contact people responsible for investigating adverse events.  This could be the ED director, the chief medical officer, OB/Gyn, and/or the risk manager. Their involvement early on is necessary for communicating to the patient what the likely possible outcomes might be and how they’re going to continue to provide care and support.  The rule of thumb is that the more severe the case, the more the institution needs to pull together quickly to discuss what’s going to be said, how it’s going to be said, and who is going to say it. Third, there will be a point person who will follow along with the patient and be continually communicating. This should not be the initial treating provider.   All hospitals should have the infrastructure to provide ongoing support to patients when untoward events happen. What is the best way to deliver bad news and apologize effectively? [21:20] The core of an apology is an explanation which demystifies the offense, but does not excuse it. Make sure that the facts (as you know them) are delivered. Don’t go above and beyond what you think you can explain. And don’t blame yourself or anybody else.  Be honest and transparent. Deliver it in a way that makes the patient feel supported. At Smulowitz’ institution they have put in place “Just-In-Time” coaching.  When something bad happens, you can page someone who has years of training and can coach the provider on what to say, what not to say, and whether he/she is the right one to say it. The University of Michigan made the CARe program an institutional process. What happened after they started using it?  [22:05] They saw a dramatic reduction in the number of claims, the number of lawsuits, and overall costs related to lawsuits. Equally  important, there has been a dramatic increase in the number of incident reports. Those results have been replicated at several other large institutions.  What are the barriers and strategies for implementation of CARe programs? [25:55] Providers are wary of it.  They feel vulnerable. Hospitals are worried they will be paying a lot of money due to an increase in lawsuits. Some plaintiff and defense attorneys are against these programs.   References: Bell SK, Smulowitz PB, et al. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q. 2012 Dec;90(4):682-705. PMID: 23216427.   Davis, Erika R. I'm Sorry I'm Scared of Litigation: Evaluating the Effectiveness of Apology Laws. The Forum: A Tennessee Student Legal Journal. Vol. 3. No. 1. 2016.    Mello MM, et al. Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Aff (Millwood). 2014 Jan;33(1):20-9. PMID: 24395931.   Shostek, Kathleen.  Communication and Resolution Programs:  Where are we now?  American Society for Health Care Risk Management. 2017 Jun 28.   McDonald, Timothy B., et al.  Implementing communication and resolution programs: Lessons learned from the first 200 hospitals. Journal of Patient Safety and Risk Management. 2018 April 11. LeCraw, Florence R., et al.  Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee.  Journal of Patient Safety and Risk Management 23.1 (2018): 13-18.

In this episode we discuss the elements of documenting a patient's decision-making capacity, pearls from the last month of ERcast, our new newsletter, and Carl Sagan's Pale Blue Dot.   Links from this episode Sign up for the ERcast newsletter HERE THIS is the newsletter discussed in today's podcast If you want to learn more about the full on, full cowbell, full BAFERD, total ERcast experience, Click Here In case the links above don't work URL for newsletter discussed in this podcast: https://mailchi.mp/hippoed/some-things-just-dont-work-on-a-podcast-2090489 URL for newsletter signup: https://mailchi.mp/hippoed/ercastnewsletter

Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone.   ERcast 2.0 Launches May 1 Click hereto learn more Or hereto sign up and skip the details   In this interview we cover a wide range of topics including Underwear How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist Meditation The Mind Illuminated The roots of anxiety Mental preparation before giving a talk ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement Nurse practitioners   A Smattering of Performance Improvement, Stress Management, and Wellness Episodes Finding the Joyin Your Job Performance Coach Jason Brooks Making Order Out of Chaos How to Not Freak Out When Consultants Give Bad Advice Beating Stress and the Hot Offload Mastering the Storm   Full Video Interview Below   https://www.youtube.com/watch?v=bujZmXEtuHA   My Favorite Zdogg Song https://www.youtube.com/watch?v=NAlnRHicgWs  

A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.   Mentioned in this episode ERcast 2.0launches May 1, 2018 To sign up for the new site and 1 year of free CME, click here Essentials of Emergency Medicineis just around the corner. If you can't make it to Vegas, the digital live stream is pretty sweet.     New IDSA C Diff Guideline Treatment Recommendations   Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5) First Line Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO  BID for 10 days Second line Metronidazole 500mg TID PO for 10 days   Initial Episode, Severe (WBC >15k, creatinine >1.5) Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO  BID for 10 days   Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon) Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present   First Recurrence • Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR • Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR •  Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode     Photo Credit Photo by Gabor Monori on Unsplash     The Guidelines McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280 Original Studies Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597 Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937 New Evidence Favoring Vancomycin Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306 Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326 CDC C. Diff Statistics   New York Times article on the association of the rise of new sweeteners and the rise of C. diff. The Germs That Love Diet Soda

In this corner, former editor of EM:RAP, coproducer of EM Essentials, creator/editor in chief of ERcast, and… the coolest dude you’ve ever known! Dr. Rob Orman! (Applause, Cheering, Etc.) In the opposing corner boring, old, and tired… Your current pre/post shift routine and some of your beliefs about your first year as an attending! Welcome to a sold-out podcast that only VIP’s like you with the link have access to! You’re welcome! Listen as Rob “The Doc” Orman strikes like lightning against what you thought you knew! He masterfully dissects some of the most difficult mental obstacles to your first year as an attending! Believe the hype! Let’s get ready to rumbleeeeeee! Hangout host: Dr. Liang Liu Podcast editor: Dr. Aron Slear

In this episode, we take a quick look at some info from a recent ERCAST w/ Rueben Strayer on the use of Haloperidol in chronic pain patients and as a pre treatment for the psychoperceptive affects of ketamine.  We dive into my plans for attending the AAEM Scientific Assembly in San Diego and wrap up with plans for our upcoming shows.....hope you enjoy!!  And like I always say, 'Don't take my word for anything.  Educate yourself and evaluate the evidence!!'.

Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.   Sign up for the ERcast mailing list Are patients with PNES ‘faking it’? PNES is a conversion disorder: an unconscious manifestation of psychological trauma. Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy PNES is not ‘faking it’ or lying   Challenges Patients with PNES may also have true epileptic seizures Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out   How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it? PNES Seizures related to a specific stimulus (sound foods, body movement) Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude. Maintenance of consciousness and may have some of the below may guard the face with passive hand drop resist eyelid opening visual fixation on a mirror Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES.  If they grimace, probably not an epileptic seizure. Faking Seizures Talking Purposeful movement Avoids injury May use convulsions as a way of harming staff Intermittently awake and vocal during the episode Epileptic seizure Convulsive frequency decreases, amplitude increases as seizure progresses No response to pain Allow passive eye opening   A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures. Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor Urinary incontinence, more common in epilepsy, but does happen in PNES. Post-ictal recovery period. Surely, this is the sine qua non of epilepsy.  It is way way more common following generalized epileptic seizures but happens in around 15% of PNES. The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES   Walker’s take home points PNES patients aren’t ‘faking it’ This is a real disorder, it's just not epilepsy References Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733 Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136  Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand. "Presenting the diagnosis of pseudoseizure." Neurology 40.5 (1990): 756-756. Full Text PMID:2330101

In the edition of the Ercast journal club thrombectomy in pts with delayed stroke presentation shows promise beware behavioral changes after procedural sedation kids with isolated linear skull fractures have a good short term prognosis procalcitonin may help decrease abx use in respiratory infections steroids in mild sore throat help... a little   Registration for ConCert (the big board recertification exam we take once a decade) has opened. If this is your year to take the exam, there's only one place to go for board review.   The DAWN Trial Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2017). PMID:29129157 What happens when thrombectomy is done when last normal was over 6 hours ago? 206 patients with occlusion of the intracranial internal carotid artery, middle cerebral artery, or both these were patients excluded from TPA because of time from onset or they had persistent occlusion despite TPA Pts had to get either perfusion CT or diffusion weighted MRI to see if there was salvageable brain (there had to be) 107 got thrombectomy and 99 didn't. 90 day functional independence: 49% thombectomy vs 13 % controls No significant difference in symptomatic intracranial hemorrhage or 90 day mortality Trial stopped early because of superiority of thrombectomy Majority of patients were wake up strokes, a group we've had pretty much nothing to offer previously Industry sponsored, many conflicts of interest   Rob's take-This trial uses salvageable brain as a determinant of treatment which makes sense as these are the patents who may actually benefit from reperfusion. This purports to speak for the patient 6-24 hours, but from what I can tell, treatment was heavily skewed toward those with time from last normal 16 hours and under, so it doesn't really tell us much about 24 hours. I will be consulting stroke centers with this patient cohort. Adam's take- Impressive. I like that this is tissue based, not time based.     Skull Fractures in Kids Bressan, Silvia, et al. "A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children." Annals of emergency medicine (2017). PMID: 29174834  Are pediatric patients with isolated skull fractures at increased risk for short term adverse events? Pool of 21 studies, over 6,000 kids with isolated skull fractures. One required emergency neurosurgery, none died. All kids had CT scan or MRI to exclude intracranial injury 6 out of 570 had bleeding on a second scan and zero had surgery. The incidence of delayed hemorrhage is super low and even those with bleeding didn't need an intervention. Unless there is a change, you don't need to rescan.   Author take home: "Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns." Rob's take-An otherwise well appearing child with isolated skull fracture has an excellent short term neurosurgical prognosis and probably don't need hospitalization based on the skull fracture alone Adam's take-Open and shut case. One kid out of over 6,000 is pretty good odds and that one patient got meningeal repair.     Procalcitonin is dead. Long live procalcitonin Schuetz, Philipp, et al. "Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis." The Lancet Infectious Diseases 18.1 (2018): 95-107. PMID: 29037960 Over 6,000 patients with respiratory infections Decision to give antibiotics based on procalcitioin level Primary endpoints: Mortality, treatment failure Secondary endpoints: Antibiotic use No significant difference in death, treatment failure, ICU length of stay Antitiocis initiated 86% controls, 70% procalcitonin guided and  shorter duration of abx using procalcitonin as the guide Fewer Abx side effects with procalcitonin guided therapy   Adam's take-This is not a lifesaving study, this is a safety study. The point is, can you safely withhold antibiotics from people? This study says you can, based on procalc level in a patient with respiratory infection. The scenario I envision is someone with CHF, COPD, fever, and coughing. If the procalc is low, I don't have to add a horrendous quinolone to your 25 other meds, you can take tessalon perles and do better. I'm going to keep one more abx prescription out of the pool and it's not going to harm the patient. This is a noniferiory trial to me. Prescribing fewer antibiotics is a worthwhile goal to me. We know that using procalcitonin for that purpose works and this study says it is safe.   Steroids for sore throat Little, Paul, et al. "Effect of oral Dexamethasone without immediate antibiotics vs placebo on acute sore throats in adults: a randomized clinical trial." JAMA 317.15 (2017): 1535-1543. PMID: 28418482 RCT of 576 adults with sore throat not requiring immediate abx. Treated with either steroid or placebo Most afebrile and did not have pus on tonsils Results: Symptoms better at 48 hours (but not 24) with dexamethasone   Rob's take- Set the expecation that it will take 48 hours to start feeling better if giving steroids. That being said,  I don't think that steroids are worth it in most mild sore throat patients. NSAIDS, tea, and time Adam's take- A cofounder for me was that 14% of the dexamethasone and 19% of no dex group had strep, a confounder I don't like. Steroids probably work a little, they're probably safe, but they're not amazing   The Brain Does Not Love Ketamine as Much as You Do Pearce, Jean I., et al. "Behavioral Changes in Children After Emergency Department Procedural Sedation." Academic Emergency Medicine (2017). PMID: 28992364  82 kids received ketamine for procedures in the ED Most had forearm fracutres Most had analgesia before procedure 22% with negative behaviors changes after discharge. Anxiety, aggression, withdrawal, sleep anxiety, separation anxiety Higher odd of this happening in kids anxious before procedure, nonwhite   Rob's take- ketamine is an excellent drug, but can have lasting effects. Also, it's not totally benign, one patient had over 30 seconds of apnea. Still one of our best options, but discuss with parents the post discharge behavioral changes that might occur Adam's take- I don't think this is a study about ketamine at all. This says nothing about ketamine, this talks about procedural sedation. There is a long history of research about general anesthesia that shows a similar pattern- post op kids have behoaboiral disturbance a week after and the kids who come into the OR have worse outcomes, and if you treat the anxiety before the procedure, they have better outcomes.This could have been propofol nitrous, whatever. The kids who start out anxious pre-procduere have a much higher incidence of behavioral disturbance post procedure.In my opinion, this study shows that anxious kids are more likely to be disrupted by this experience than non-anxious kids. I am going to give a lot more versed. Maybe this is the versed indication that works with ketamine.

One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.    Episode Guide In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17). Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain. A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects. Haloperidol is an analgesic option for patients taking chronic opioids. Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV,  5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose.  If that doesn’t work, he uses analgesic dose ketamine. For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum. Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses.  Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check. Check out Reuben's blog Emergency Medicine Updates and follow him on Twitter   References Opioid Hyperalgesia Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text link. PMID: 21412369  Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link.  PMID: 21029354 Droperidol for analgesia Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396.  PMID: 20832967 Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279 Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073 Early studies on Haloperidol for analgesia Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741 Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10. Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130. Haloperidol for pain Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669 Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990 Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034

The tables are turned when ERCast host and emergency medicine physician Rob Orman hijacks the show! Video and comments here: https://www.facebook.com/ZDoggMD/videos/10156013476917095/

Sam Ashoo is an ED doc practicing in Tallahassee, Florida. He has been an ED director, coding and billing chief medical officer, international educator, and runs the Admin EM blog. That blog name might sound nerdy (and it is) but his short write ups on common clinical problems are famously high yield. In this episode, Sam gives his strategies on what to do when the consultant on the other end of the phone call is giving questionable advice. Before jumping in to the episode, take a few minutes for the ERCast listener survey.The survey lets me know who you are, what you do, and what you need when it comes to medical education. Thanks in advance.   Discussion topics Are you disagreeing with your consultant or is the information you are being given simply wrong? Why determining the root cause of the bad advice can help lead to resolution of conflict Should you apologize for bothering a consultant when you call them? What to do when a consultant is dismissive of your concerns about a patient Factors that may lead to questionable advice from a consultant Bad advice is usually not malicious (even though it may feel that way) Be aware of downstream effects of negative interactions with consultants   Bonus Content What follows is a summary of a conversation with Dr. Jim Adams, Chairman Northwestern University Emergency Medicine. He is a master of conflict management, resolution, and prevention How to insulate ourselves from the stress of conflict with consultants Get to know them personally. Build social capital and friendships. We underestimate the power of social connection to prevent negative interactions. Slow down before you make the call and think about why you're calling. Know your needs and know your ask. (example of rambling vs focused). Don't give your consultant an order, call with a specific need. Speak at a measured pace. While you may think you sound calm and friendly, it's possible that what's heard on the other end of the line is pressured, pushing, and curt. Trainees and new attendings are especially vulnerable to this. It's not a mystery why this happens-your work environment is the perfect setup for the opposite of a calm phone presence. At baseline, the ED is high pressure and there are myriad demands for your time and attention. When you sound pressured, the person on the other end of the call feels pressured, then they match your tone... and then YOU think that THEY are the problem! Consider reciprocity when dealing with an irritated consultant. If you're irritated, they're irritated. It's infectious. If you choose to be happy and express appreciation for the consultants advice or coming in, that changes the dynamic. If you lead with irritation when they come into the ED to evaluate a patient, what do you think is going to happen 9 times out of 10? Your consultant will be more irritated! When you get a hard time on the phone, your brainstem screams "threat, aggression!" You start to get angry and want out of the conversation. That is a primitive conversation. Your emotion is now driving you. Take some reset breaths, try combat breathing, recognize and be in control of the emotional response At the end of the conversation, show appreciation for the consultant's expertise. If it's a surgeon, Jim says, "It looks like this patient needs your hands." If it's an internist, he might say, "It looks like this patient needs your time and wisdom." That may sound lame/dorky/fake/etc but you are doing two things: expressing gratitude and making them feel needed. Feeling needed is irresistible for doctors (or pretty much any human) - it makes them feel good about their jobs. Even if they're tired and cranky, making someone feel needed and valued leads to better interpersonal results. In any conflict, there is a moment when you should stop listening to what they're saying and focus instead on why they're saying it. Often a consultant that is giving you a hard time or is dismissive may not be in  position to help you at this moment (they might busy, tired). you may also have a consultant who acts like a bully and tries to dominate you in a conversation. They may in fact just be a bully, but sometimes it's a case that where they have nothing to offer the patient. When a person is not giving you answers that are not acceptable, find the things that you'd agree on that are acceptable. When there is a negative interaction, let your department chair know. On investigation, what's often uncovered is burnout, depression, substance abuse, going through a divorce, etc. Of course, some people have grown accustomed to exhibiting rude behavior and it has nothing to do with other life circumstances.   The Case You are seeing a patient with a VP shunt who is having repeated seizures. They are followed by a neurosurgeon for all of their neurologic related needs (the family called the neurosurgeon who recommended they come see you). After a workup in the emergency department, it's still not clear why the patient is having seizures. You call the neurosurgeon and the response is something like this, "Why are you calling me? This patient doesn't need surgery. Do you understand what I do? I am a neurosurgeon, that means I do brain surgery. This patient doesn't need that." You reply, "I understand that, but you recommended the patient come to the ED, they are your patient and have complex brain hardware so I thought you'd like to know what's going on and we could discuss treatment options." "I'm not sure why you can't understand what a neurosurgeon does. Are you a doctor..." If the consultant has a truly pathologic personality, there's no magic fix or workaround. Just don't take their derision toward you personally. You'll find that they are exhibiting the same behavior in every part of their life. There are other paths you can take besides wanting to smash the phone into the desk in a fit of rage. Your primitive brain is exploding right now, begging to go full caveman here. Take a breath, stay calm and measured and use the technique of BLEND and REDIRECT Blend - restate what you do agree on and Redirect- see if you can align with them to help the patient. Blend "I think we can agree this is a really complex patient. There's nothing suggesting they need acute surgery."  Redirect "But they're having this problem and I need some guidance on how to best help this patient and family." You are blending with what they're saying and redirecting them toward your need and seeing if they can help provide a solution.   The solid Before you go, take a moment for the ERCast listener survey. It's short, sweet, and full of info that will help me help you. And since you've gotten this far on the blog, I'll also tell you that there's a $50 Amazon gift card up for grabs.

Jason Brooks PhD is a performance coach helping health care providers, athletes, and other high level performers live better, work better, and be better. In this episode Jason gives his strategies and tactics on myriad topics including: three techniques for stress inoculation, improving test taking, the unseen costs of hiding ignorance, and what habits are common among high level performers.   Episode Contents A look back at ERCast episode one on Rectal Foreign Bodies Jason's work with physicians through Phenomenal Docs You can't stop the waves but you can learn to surf - Jon Kabat Zinn Who consults a performance coach? Those who are stuck and want to become unstuck. Those who are excelling and want to excel at an even higher level. These forces can exist simultaneously in the same person What's easier to accomplish? Moving from a perception of low-level performance or getting to a higher level of excellence? Answering the question, "Why is this happening to me?" Start with Why by Simon Sinek Book TED Talk Having an internal yardstick to gauge how decisions align with your values Making time for periodic reflection The importance of adversity It's not what we do that causes burnout, it's losing sight of why we do it Common habits of top performers that transcend a particular career Humility is a common attribute in high level and respected performers driven to be the best I can be, but I don't have all the answers Expectations of a master physician to learners: make me better by contributing to my knowledge base, and I expect you let me know if you think I'm making a mistake Shedding the fear of exposing ignorance. What is the real cost of not exposing ignorance? Leaving knowledge on the table Three techniques for stress inoculation Practice through visualization Breathing techniques to trigger parasympathetic response and mitigate sympathetic fight/flight/flee Using a trigger word to de-escalate stress (mine is "level down") Improving test taking performance How an Olympic archer recalibrates after missing a shot Connect with Jason: Facebook, Twitter, email doctorjbro at gmail dot com    

Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a Download Leave a Comment Tags: ACE Inhibitors, Allergy/Immunology, Angioedema, Icatibant Show Notes Take Home Points Airway management is paramount, expect a challenging intubation and consider controlling the airway early When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can't intubate, can't oxygenate scenario with a double set up. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment Finally, observe the patient for progression of swelling and don't forget to stop the inciting medication Read More Core EM: Angioedema EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC ERCast: Angioedema

Prompted by the recent CAMEO trial publication on icatibant, we dive into angioedema with a focus on airway management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_107_0_Final_Cut.m4a Download Leave a Comment Tags: ACE Inhibitors, Allergy/Immunology, Angioedema, Icatibant Show Notes Take Home Points Airway management is paramount, expect a challenging intubation and consider controlling the airway early When controlling the airway, consider an awake approach and fiberoptics if available. Always be prepared for the can’t intubate, can’t oxygenate scenario with a double set up. If the patient has urticaria and pruritus, the process is likely histamine mediated and will respond to typical anaphylaxis treatment Finally, observe the patient for progression of swelling and don’t forget to stop the inciting medication Read More Core EM: Angioedema EMCrit: Podcast 145 – Awake Intubation Lecture from SMACC ERCast: Angioedema REBEL EM:

每月收聽的急診Podcast清單： EMCrit http://emcrit.org/ ERCast http://blog.ercast.org/ EM:RAP （付費訂閱） https://www.emrap.org/ EMCast （付費訂閱EMedHome.com） http://www.emedhome.com/cme_emcast.cfm 目前使用的android app.: AntennaPod http://antennapod.org/

This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging? https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_30_0_Final_Cut.m4a Download Tags: Cervical Spine, NEXUS C-spine, Pediatrics Show Notes Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905 ERCast: Pediatric C-spine Clearnace PECARN Decision Rule

This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging? https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_30_0_Final_Cut.m4a Download Tags: Cervical Spine, NEXUS C-spine, Pediatrics Show Notes Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905 ERCast: Pediatric C-spine Clearnace PECARN Decision Rule

This episode delves into pediatric c-spine injuries focusing on the question of who needs imaging? https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_30_0_Final_Cut.m4a Download Tags: Cervical Spine, NEXUS C-spine, Pediatrics Show Notes Leonard JC et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011; 58(2): 145-55. PMID: 21035905 ERCast: Pediatric C-spine Clearnace PECARN Decision Rule

This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_28_0_Final_Cut.m4a Download Leave a Comment Tags: Depression, Suicide Assessment Show Notes ERCast: Suicide Risk ERCast: Is My Patient Suicidal Columbia Suicide Severity Rating Scale Read More

This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_28_0_Final_Cut.m4a Download Leave a Comment Tags: Depression, Suicide Assessment Show Notes ERCast: Suicide Risk ERCast: Is My Patient Suicidal Columbia Suicide Severity Rating Scale Read More

This week we review some of the different aspects used in assessment of the suicidal patient who presents to the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_28_0_Final_Cut.m4a Download Leave a Comment Tags: Depression, Suicide Assessment Show Notes ERCast: Suicide Risk ERCast: Is My Patient Suicidal Columbia Suicide Severity Rating Scale Read More

Rob Orman drills down on what suicidal ideation really means and how you can tell if your patient really has it.