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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena. Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia. Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass. Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome. Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever. Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding. Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site. Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis. Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients. Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks. Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena. Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss. Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation. Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia. Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction. Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss. Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months. Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively. Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it. Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia. Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention. Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia. Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon. Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used. Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v. Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned. Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis. Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery. Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds. Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care. Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat. Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation. Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg. Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views. Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners. Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon. Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population. Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper. Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients. Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia. Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia. Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints. Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia. Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel. Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed. Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray. Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients. Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed. Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast. Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies. Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia. Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously. Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC. Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients. Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however. Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate. Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children. Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life. Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs. Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities. Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother. Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes. Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate. Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition. Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months. Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake. Nachi: Pretty cool stuff... Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections. Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility. Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition. Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon. Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon. Nachi: Exactly. Let’s close out with some Key points and clinical pearls. Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities. Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities. Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy. Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis. Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting. Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena. Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication. Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release. Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention. Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated. Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration. Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications. Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis. Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions. Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage. Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology. Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel. Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology. Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients. Nachi: So that wraps up Episode 30! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References Altieri MS, Wright B, Peredo A, et al. Common weight loss procedures and their complications. Am J Emerg Med. 2018;36(3):475-479. (Review article) Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014(8):CD003641. (Cochrane review; 22 trials) Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21 Suppl 1:S1-S27. (Society practice guidelines) Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism. 2018;79:97-107. (Review article) Contival N, Menahem B, Gautier T, et al. Guiding the nonbariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155(1):27-40. (Review article) Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient, 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. (Society practice guidelines) Chousleb E, Chousleb A. Management of post-bariatric surgery emergencies. J Gastrointest Surg. 2017;21(11):1946-1953. (Review article) Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25(4):622-627. (Retrospective review; 7328 patients) Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. (Society practice guidelines)

Jeff opens the show talking about the work he's doing on the manuscript for the Hat Trick re-release. New patron Lucy is welcomed. The guys talk about Tales of the City on Netflix and the new season of Pose on FX. Will reviews Anticipating Disaster by Silvia Violet while Jeff reviews Prince of Killers (Fog City #1) by Layla Reyne. Jeff interviews Layla Reyne about the new Fog City series as well as how it felt wrapping up the Trouble Brewing series earlier this year. They also talk about Layla's RITA nominated book, Relay, and the upcoming fall release, Dine with Me. Complete shownotes for episode 193 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript – Layla Reyne This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Welcome Layla back to the podcast. It’s great to have you here. Layla: Thank you for having me back. Jeff: I had to have you back to talk about this new series, “Prince Of Killers,” as listeners will have heard right before this interview, blew my mind to pieces and back. Layla: That’s what I wanna hear. Jeff: Tell everybody what this new series is and in particular what they have to look forward to in “Prince Of Killers.” Layla: Sure. So the series is “Fog City.” It’s set here in San Francisco. It’s a new romance suspense series. You don’t need to have read any of my series before that. I won’t say that there aren’t some Easter eggs for those that have, because we are all existing in the same place and time. But, this is a little different because this is following a family of assassins. So in books one to three of the “Fog City” trilogy, starting with “Prince of killers,” you’ve got Hawes Madigan, who runs a cold storage business by day, a very successful family kind of business in the city. And then by night, the families, they’re assassins. And he and his two siblings, Helena and Holt, are kind of the triumvirate that is currently the heir apparent. He’s the heir apparent and they kind of all run it together. His grandfather is ailing and so that’s kind of the setup and fairly successfully he is making some changes in the organization. And so in comes…in the first scene, which is actually set at one of my favorite restaurants in the city, Gary Danko, walks Dante Perry who kind of has this strut about him, you know, long hair, looks like a rock God. But he’s carrying a gun, which he immediately notices, Hawes does, and Perry tells him, “There is someone trying to kill you.” And Hawes kind of laughs it off to start with because, dude, he runs an organization of assassins. That’s what they’re paid for. But then as Hawes and the family come to learn, it does look like someone is trying to stage a palace coup, so to speak. And so “Prince Of Killers” involves sort of the first stages of that and them trying to figure out who it is. And Dante has his own motivations as well. You know, he is trying to find the killer of someone who was close to him and Hawes doesn’t want him to find out who that is either. So I will leave it at that without spoiling too much. Jeff: Let’s talk about the elephant in the room a little bit, and that is the fact that while you have left, for example, the books of the Whiskeyverse on some subtle cliff hangers, this one’s bigger than normal for you. Layla: Yeah, I’m not hiding anything, guys. This one’s got a cliffhanger. I wouldn’t say anyone’s life is in jeopardy, but it’s definitely a cliffhanger. I have made no bones about that “The Usual Suspect” is one of my favorite movies. So hello. And, you know, I grew up in TV land and so I love cliffhangers and I kind of embrace it with this. And, you know, the good thing is the plan is for all the books to be out this year. All the covers are done. By the time this airs, book two will be in the hands of editors and I should be working on book three by then. So, they will all come this year and it’s in the blurb. So you know, everybody, fair warning. I’m not trying to hide it here. So… Jeff: Yeah. And I love how you make the analogy to TV because I would put the cliffhanger that you did on the level of like the mid-season break. Not quite the end of season break, but that mid-season, it’s Christmastime, we’re gonna go away for a while and we’ll have a big thing when we come back. Layla: That’s right. It’s the end of November sweeps. Jeff: Exactly. Layla: That’s where we’re at, not gonna lie. And then book two picks up right where it ended and goes on in there. Jeff: Yeah. Which I’m super looking forward to. Layla: I’m writing. It’s been a…It’s fun and, you know, I can’t…yeah, I can’t spoil anything. Jeff: Yeah. Don’t say anything else. I don’t wanna know. I don’t want the listeners to know. Layla: Okay. Okay. Jeff: What was the inspiration for “Fog City” overall? Because since you’ve gone with this family of assassins, it’s certainly different from what we’re used to in the Whiskeyverse where you’ve got all the, you know, FBI agents and other kinds of, you know, law enforcement as your main characters. Layla: So ironically, I was wandering through Wander Aguiar’s photography website looking for covers for a different project and I saw this picture of what will be the book three cover. And I had to know what the hell is their story. I mean it just jumped at me and I was like, I have to know the story. And then one of my good writer friends, Allison Temple said, “You can’t buy the pictures until you have a story.” She’s like, “Do not spend the money.” So by the end of the weekend, I had the story. I had all three of them and then I was like, “Okay, so let me piece together the three covers.” And so that’s kind of how it, in its original, came about, you know, thinking about doing it. So art really did inspire art in this case because the photos were just amazing. I wanted to branch out and do a little bit of something different. There have been hints of the people in the gray area, you know, Jamie, good guy, but some of that hacking is not exactly on the up and up. Mel, I think we saw go more and more, you know, in her bounty hunter business and be a little bit more flexible once she left the FBI. And so kind of going from there and wanting to play more in that gray area and having read books too, L.J. Hayward’s “Death And The Devil” series, in particular, you know, it’s fun and it’s to some extent pretty liberating. I don’t think it was…it wasn’t harder. There are less rules. Right? I don’t have to check the FBI’s hierarchy chart every day to make sure I’m naming someone the right position. So in that regard, it’s actually been a bit easier. Jeff: Your shades of gray is 100% right because it’s not a spoiler to say that Hawes, not only did he have the legit business on the side, but he’s even trying to modify the ways that the family does the assassin business to make it, I guess, less bad maybe. Layla: Yeah. So, there’s an event that happened three years ago that kind of drives a lot of the series and when you read you’ll find out what that is and to the extent it drives Hawes’ three rules, which are in the blurb, which is no indiscriminate killing, no collateral damage, and no unvetted targets. So, if they’re not…He is turning the organization away from kind of the killing machine that his grandfather, Papa Cal, was. And his parents were very methodical, very efficient, not a whole lot of emotion in it. And so, he’s trying to find the balance between those two of it being, you know, I don’t wanna say the killer with a heart of gold, but he is a killer with a conscience. And so he doesn’t even like the moniker Prince of Killers and what that stands and how it came about, which you’ll read about in the book as well. So, he’s definitely a great character. And then when you look at the broader picture of everyone in the series, Holt is, you know, this…he has a kid and he is, first and foremost, a father, right? And he is a hacker and he, because of where he’s at in his life, has pulled back to being kind of the digital assassin of the bunch. And then Helena, who is the sister, who is my typical female complete badass, love her, she works for…she does a criminal defense work in her day job where she is actually working for people who are wrongfully accused. And so there’s some shades of gray in her as well. And then even one of the other side characters is the chief of police who has an interesting relationship with the Madigans and he knows that there is some benefit to what they do and you’re gonna find out there’s some backstory with him as well as to where he is. So, there’s a reference to him in…If you’ve read “Trouble Brewing,” there’s a reference to him in “Noble Hops.” It’s the same chief, for those who are watching, that read that. So… Jeff: That was one of the Easter eggs that I missed. Because you and I have talked about the Easter eggs and there was some that I caught it and some was like, “Dang it.” Layla: So that’s one of…he’s the new chief, you know, that’s a little bit more flexible in the way things are done. And so everybody…and then Dante is also, you know, playing in his shades of gray as a PI and how far he’s willing to go and what he’s doing personally and professionally. Like where’s that line for him? Jeff: Helena is the one that I found the most interesting in her shades of gray because here’s an officer of the court who occasionally does some, you know, very illegal things, which isn’t to say that, you know, all lawyers are, you know, on the right side of the law. But for her, it seemed like really… Layla: Right. And she makes a line about balancing out her karma, right? That’s kind of how she approaches it to some extent of, you know, part of what they’re doing and why he…particularly Helena and Hawes are so well aligned like that, you know, Hawes wants the contracts of the people the law can’t reach or that escape the law, you know, who get around it, let’s just say, because of who they know or who they pay. And that’s kind of who their targets…that’s the targets he wants. People that have, you know, skirted justice for nefarious reasons. And her day job is the people who justice has wrongfully done. And so they kind of work hand in hand and her feeling on it plays to both of her careers. Jeff: You mentioned in this book you had less rules, so like, you’re not looking upon the FBI flow chart and things. Were there challenges to coming at these characters who had these shades of gray or was it…”free for all” is a little bit much, but certainly more freeing I guess. Layla: Yeah, certainly challenges. Though, I mean, you still have to balance the fact that, “Hey, they’re killing people.” Right? And how you balance that with their conscience, with the people around them, particularly Kane, who was the police chief, has a lot to deal with and going on kind of. So yeah, I mean it is definitely there. There were different challenges for me, I kind of liked it because I got to go a little bit more, even though it’s a shorter book than usual, I think going into their heads more than I typically would because there’s a lot more internal conflict – while still having tons of external conflict. I felt like there was more internal conflict about what they’re actually doing than, you know, being an FBI agent and knowing you’re on the right side of the law. So this was more…they had to kind of walk that line, particularly Hawes. Jeff: One of the things I like most about the book that is…in a lot of ways, it’s separate from the romance and it’s separate from the suspense element a lot is the family unit. And it’s a recurring theme, at least in the books that I’ve read of yours from, you know, Irish And Whiskey and their families. And then what we see of the families in “Trouble Brewing” of the main characters. And here I really feel like maybe it’s because we’re so much closer to the family that we really, even in the shorter book, get a lot about Hawes and Holt and Helena and their interaction with each other. What was your plan as you like populated this family and the characters that you wanted to put on the page? Layla: So, it kind of, I would say, came about organically to an extent. The first scene I wrote like that weekend when I saw the pictures, I wrote it and then I posted it in my little reader group’s like, “I hate you.” And in that first scene, actually there’s a reference to the siblings, but you actually don’t see them, but then they pop up. And part of it too was I had already found their pictures as well. I kind of knew who they all were, but, I also knew who we needed to do X, Y, and Z from a plot standpoint. I also didn’t want Hawes to be an island to himself. Right? And to some extent, giving the life that he lives. And, you know, the two aspects of his life, that family is gonna be the only…like they can’t really let anyone else get close. Right? And so, they’re so tight with the family. That’s the only people they trust. And so, that’s, I think, particularly why, you know, that’s who he debriefs with. That’s who they’re planning with and everything because that’s kind of it. And then, sort of, you have in that expanded family, you also have Holt’s wife, Amilia, and you have the grandmother, Papa Cal’s wife, and like that’s the tight-knit crew. And it has been that way for that family for three generations. And that’s kind of what you find out is that, this is what they do. And because of that, they have to keep it close to the vest and the families who they trust. Jeff: But even through that, you’ve got Helena pushing on Hawes to make the connection to find somebody. Which I love because even as all hell’s breaking loose, it’s like think about doing that because you could have what Holt has. Layla: Yeah. They both…you know, Holt’s happily married with a kid. And I think for both, for Hawes and Helena, you know, that’s the ideal. Their parents were happily married, right? Papa Cal and Rose were. So you can have happiness, right, in this. You just have to find the person who accepts it and where’s that line? And Dante is someone who could be that person, right? He comes in and he seems to know what they do. He seems to be okay with it. And it’s got a hint of insta-lust for sure. Like they’re immediately attracted to each other, but it’s not until later where Hawes kind of starts to think, “Huh, here’s this person who maybe gets it and is okay with it,” the way that Holt and Amelia ended up working out. And Amelia is part of the group, she actually has her own specialty with pressure points and being kind of a perfect Trojan horse for the group because she’s not as out there as the rest of the Madigans are with the business. So yeah. So, he starts to see that. And Helena is kind of also walking a thin line of, “I wanna be happy, but do we know who this dude is?” Right. “Hey, Buddy. Okay, go have fun. But be careful.” So, he’s trying to be the rational one in that scenario. Jeff: So, we know that this is a trilogy. How far does “Fog City” go overall? Do you have a grand plan? Layla: I do, I do. Hawes and Dante will have a trilogy. So they’re the main characters through books one to three. And then Helena will have a book and then there’s another fifth book, but I’m not gonna say who that is because that’ll spoil things. But everybody will get their HEAs by the end of it. I’m looking at five and then I’ve got some ideas for spin-offs and I may already have some cover photos bought for them. I would say I like building big verses, right? I mean, I grew up…I mean my intro to really reading a lot of romances, Kristen Ashley, and I love that big verse concept. And so I like building them too. Jeff: And if you, you know, put it back on TV, I mean, you look at things like the Arrowverse and all of its characters or all of the Chicago shows on NBC, you can have all of your one big, huge comboverse. Layla: Yeah. No, and that’s kind of like that. I grew up in all that too. I was a TV person first. I come from that world where it is all intertwined like that. I like doing that. I like cameos and seeing characters and it’s fun. And you know, Mel runs everything, just remember that. That’s all you need to know. Jeff: Even if the characters don’t know that, she’s really in charge. Layla: Everything. Yeah. Jeff: Now, we gotta give you a congrats too because in the midst of you getting this ready, it was announced you’re a finalist for the Romance Writers of America RITA Award, for the book, “Relay.” Layla: Yes. Yes. Jeff: Which is awesome. For those who don’t know, tell us what “Relay” is about. Layla: “Relay” is book one and the “Changing Lanes” duology, which is “Relay” and “Medley.” So, two books. The duology follows the four men who are on the U.S. men’s medley relay team, swim team. And so, the first book, “Relay,” which was nominated, is about Alex Cantu and Dane Ellis, who had a little summer love affair at a training camp 10 years ago and didn’t go well because Dane is the son of an evangelical minister and very closeted. And so he ends up on the same Olympic team with Alex, who is the team captain, who’s worked his tail off basically to get where he’s at and he is…you know, it’s enemies to lovers to start. Obviously, there’s a lot of friction there from what happened in the past. And then they end up on the relay team together, have to work together. And so then you’ve got a bit of a second chance love story. That’s what it rolls into. And so you see up through the first two legs of training camp and Olympic training in the first book. So you see the two domestic sites. And then in the second book, “Medley,” which follows the other two characters, Boss and Jacob, that’s a mentor-mentee. A little bit of an age gap, like 26 to 19, I think. And Jacob’s this lovely like pirate-quoting cinnamon roll. I love him. He’s so much fun. And two bi characters. Jeff: Pirate-quoting cinnamon roll? Layla: Yeah, he’s a cinnamon roll character, like, he’s a total dork. Jeff: I love that description of him. Layla: And so, then you see international training in the Olympics in that book. So they go hand in hand. And I’m really…you know, there are definite problems with the RITA awards has been brought up with getting better representation. I am happy this book got through. Alex is a character of color. And, you know, when I wrote this, I wanted to say, you know, “This is the U.S. Olympic team, a representation that I would like to see,” right, that’s diverse in sexuality and race and, you know, I’m glad that it did get to the finalists because that’s at least out there. Jeff: And again, congrats for that. That’s cool. I’ll have to go pick that up now because I have not picked up your sports books and I’m certainly like a sports romance lover anyway, so… Layla: One of my good friends was a competitive swimmer up through college and so I talked to him a lot and then one of my other friends swam up through high school and then a little bit in college too. So, it was something different, you know, and I think it was right about the Olympics time where we started talking about that idea and then it just rolled. Jeff: As I mentioned, there was some research involved there too, just to know what the training program was like and where it happened. Layla: And then some of it was my own, like, but too, they go to Vienna for training and I studied abroad there. And I’ve kinda always wanted to put it in a book. And so that was a lot of fun – everywhere there is somewhere that I went and even the fight that happens up in the wine country kind of happened to a friend. And so it was interesting like to see kind of, it was a different source of the fight, but you know, I was traipsing through this little village in the middle of the night going, “Where’d you go?” Jeff: That’s awesome. Drawing from real life events. You’ve got a bit of a con schedule going on this year. You’re headed to BLC so you’ll be at the first incarnation of Book Lovers Con in New Orleans, but you’re also making your very first trip to GayRomLit this year. Layla: I know, I can’t wait. It’s finally back out here, relatively close to us on the West Coast. I’m so looking forward to that. You know, I loved…I’ve been to an RW International and then I went to RT last year and I love the reader interaction like that. I like that part of it so much. And so that’s why I’m going back to Book Lovers Con to get more of that, but then I really want to go to GRL because those are particularly our readers, right, and my favorite authors, so I can’t, you know, wait to meet some folks. See folks that I met last year, meet others, and then like… two of my closest writing friends I’ve never met in person, they’re both going to be there. So I can’t wait for that. Jeff: So name drop a little bit. Who are these people you’re meeting in person for the first time? Layla: Well, what’s cool at Book Lovers Con is that I’ll get to meet Annabeth Albert, who’s been a sprint partner, publishes with the same…with Carina Press too. So that’ll be awesome. But then, yeah, at GRL, it’ll be Erin McLellan, who you actually reviewed “Clean Break,” and Allison Temple. So we’re looking forward to that. Jeff: Very cool. Now, of course, “Fog City” continues through this year. I know you’ve got at least one other book sneaking it’s way out there. What else is coming up this year? Layla: So there’ll be the three “Fog City” books and then “Dine With Me” comes out in September and it’s very different from everything else. So, well, I guess not, you know, if you read my books, and even in “Fog City,” there’s food, there’re restaurants because I am a complete and total foodie. And so “Dine With Me” is kind of my love letter to restaurants that I’ve loved, to food experiences that I’ve loved. And it follows Miller Sykes who is an award-winning chef who gets a diagnosis, a medical diagnosis, and basically if he gets treatment, he will lose his sense of taste. It’s a high likelihood that the treatment and surgery will compromise the sense of taste. And as a chef, dude, how? Like even as a foodie, you know, God, I can’t imagine and I can’t even…as a chef, wow. And so rather than get treatment, he decides to go on the last tour of his favorite meals. And it’s not just high end, you know, it’s dive bars and, you know, there are high-end restaurants also all across the spectrum for everything a different place offers. And that’s partially my experiences too, everywhere there is based on somewhere I’ve been. And then Clancy Rhodes who is the financial backer for this effort is kind of along for the ride. He’s a total foodie, experiencing it, and how he starts to piece together what’s going on and also starts to realize they have a lot in common. Despite, you know, a bit of an age gap and coming from different places in different worlds, they are both kinda facing these great expectations and how to handle that. And he has to convince him that, you know, life is more than just your taste buds, right, and that love’s worth it. And so it’s the book of my heart. It’s been in my head for years. I’ve sat on the first chapter since 2015, 2016 it was on the initial list of blurbs I gave my agent, and we finally found a place to make it happen. So I’m super excited about it. Jeff: That’s awesome because it’s always good to get the book of your heart out there. Layla: Yes. Yeah. Like I said, it’s different. You know, there is a ticking clock aspect to it given the diagnosis and what’s going on but, there’s not a car chase, which is unusual. But it’s a much more internal book and a lot of food gushing. So, you know, I generally say have snacks and tissues, just FYI. Jeff: That’s not really a bad thing for any book to have the snacks and the tissues nearby. Layla: You’ll really need it. So, I’m excited. That comes out September 16 and that’ll be from Carina, that one will. Jeff: Cool. And I have to ask before we wrap up, how was it to wrap up the Whiskeyverse for now – as “Trouble Brewing” wrapped up earlier this year? Layla: Yeah. I mean, good. Right. I like where everybody got to. I loved writing that last scene in “Trouble Brewing” and “Noble Hops.” You know, it was just kind of a nice – everybody’s where they should be. Right. I was glad to give everybody their happily ever after there. I did see some things, which are in the pipeline. And so, things may happen in the future depending on time and whatnot. But I’m excited for it and I’m glad Nick and Cam and Mel and Danny and Aiden and Jamie all got their happy. They definitely deserved it. Jeff: Yeah. Yes, they did. They worked for it. Layla: They worked for it. Jeff: Yeah. It was such a satisfying read. If anybody hasn’t picked those books up, they need to for sure. Layla: Thank you. Jeff: So what is the best way for folks to keep up with you online so they can keep track of all the “Fog City” releases and the upcoming “Dine With Me” and everything else? Layla: Yeah, so probably my Facebook group, Layla’s Lushes is where I’m at the most. And you can find a link to that on my Facebook page too, which is just Layla Reyne. So, that’s me on pretty much all the platforms on Twitter, Facebook, and Instagram. I’m on Instagram a fair bit. There’s a lot of food and my pugs there, so just FYI. I would say the reader group and the newsletter too, which is on my website, there’s a banner, so it’s laylareyne.com and you can follow and find it there. Jeff: Yup. We will link to all that in the show notes along with all the books. The reader group is the place to be because it’s where you find out about like, oh, the first chapter of “Fog City” well before anybody else does. Layla: Yeah. I kind of like…I have a hard time sitting on stuff. I ran one of the big “X-Files” spoiler sites back in the day, so if that tells you anything, I’m a bit of a spoiler junkie and have a tendency to spoil things though, just FYI. Jeff: Yeah. Everybody should go join up with that if you’re into Layla’s books in any shape, form, or fashion. Layla: Yes. Jeff: All right. Well, Layla, it’s been so good talking to you. Thank you so much for the great read that is “Prince of Killers” and I look forward to keeping track of “Fog City” as the year progresses. Layla: Excellent. Thank you so much for having me again. It’s been fun. Book Reviews Here’s the text of this week’s book reviews: Anticipating Disaster by Silvia Violet. Reviewed by Will Nice-guy Oliver enjoys his quiet bookish life – so he’s less than thrilled to be attending a family reunion at a ski resort. He braves the frigid temperatures and disapproving attitudes of his extended family to please his grandmother, who he adores. Irresistibly sexy bisexual outdoorsman David is in town to help his friend mend a broken heart. While his bestie distracts himself with a pair of slope bunnies, David sets his sights on klutzy Oliver, offering to give him private ski lessons. Flirtation leads to friendship and to David accompanying Oliver to some of the planned reunion activities. When certain family members mock Oliver’s nerdish tendencies, David fiercely defends him. Can’t they see how smart and sweet and kind he is? To give Oliver a vacation from his relatives, David takes Oliver to Anticipation, the picture-perfect mountain town that he calls home. The more time that our heroes spend together, the more they think this might just be the real deal. The problem is that neither one of them does casual relationships. David has his life in Anticipation and Oliver has his life back in Florida with his grandmother. A long-distance arrangement doesn’t seem particularly practical and they sadly part ways. Oliver returns to his real life and, after some time apart from David, he realizes (with some help from grandma) that his quiet existence might be more about hiding from life than truly living it. He decides that David is well-worth the risk and heads back to Anticipation to start a new adventurous chapter in his life story. I really enjoyed Anticipating Disaster. The author takes some familiar character types and story tropes and crafts a really compelling story, while at the same time giving the romance her own twist. The set-up might be pure category romance, but let’s be real, this is a Silvia Violet book, so you know that the heat level is going to be cranked up to 11. Oliver has a penchant for lacy undergarments and, over the course of the story, David discovers he likes cute guys with a penchant for lacy undergarments – like, A LOT. Also, in the bedroom, David has a talent for turning some particularly filthy turns-of phrase. So the time our that heroes spend together do not disappoint – these aren’t the kinds of sex scenes you’ll skim over. This book is the first in a series with the quaint town of Anticipation serving as the backdrop for future installments. A few side characters are introduced in Anticipating Disaster and I look forward to the new romances that will unfold in upcoming books. Prince of Killers (Fog City #1) by Layla Reyne. Reviewed by Jeff. Anyone who’s been listening to the show over the past year knows that I’ve fallen hard for romantic suspense, and in particular the stories that Layla Reyne writes. As soon as I offered the chance to read an advanced copy of Prince of Killers I jumped on it and devoured it in just a few days. Not only is the suspense tight but the budding romance had great sizzle. I’ve never read romantic suspense where someone in law enforcement wasn’t at least one, if not both, of the central characters in the love story. In this book, our main character is on the flipside of the law as the leader of a family of assassins. This provided an interesting twist and I loved the ride. The titular prince of killers is Hawes Madigan who has recently come into leading his family’s business because his grandfather is on his deathbed. One evening, just before a job, Hawes gets information that someone inside the organization is looking to take him out and possibly targeting others inside his family. The bombshell is dropped by the mysterious Dante Perry. The news of betrayal from the inside throws Hawes for a loop. He figured some associates might take issue with the new rules he’s put into place, which include no indiscriminate killing, no collateral damage and no unvetted targets. He introduces these rules because of past incidents that haunt him. The introduction of the Madigan family and how they approach their line of work fascinated me as much as the suspense of the internal sabotage and the romance that blooms between Hawes and Dante. Hawes has a twin sister, Helena, and younger brother, Holt who has a wife and baby daughter. Holt’s the tech wizard for the organization and Helena has another career as an attorney helping those who are wrongfully accused. Hawes’s life revolves solely around the family businesses–both the legit refrigeration business and the not-so-legit assassin game. The interplay of the family members as they try to sort out the traitor in their midst while dealing with their dying grandfather is so sharply written. There’s barely time for them to process any one thing that happens and yet the do make time to support and care for one another. Helena even pushes Hawes toward Dante as a potential partner because she wants her brother to have someone. Hawes taking the leap to trust and fall for Dante is one of things I love most about the book as he finds the strength to overcome the fear of putting his family at risk. Even though Holt has made a family for himself and his parents and grandparents had a successful family life, Hawes feels that he needs to be cautious since he’s the family leader now. Dante also goes out of his way to get Hawes and the family to trust him with not only their brother’s heart but aspects of the business as well. Hawes using Dante as his rock as the plot against the family unfolds, exposed his vulnerabilities perfectly. Meanwhile, the bombs that dropped in the final quarter of this book were ones I hadn’t seen coming and got my heart thumping. This is book one of a trilogy and as was the case with Layla’s other books I can’t wait to see where she takes this story. Similar to the Irish and Whiskey and Trouble Brewing trilogies, the Hawes and Dante’s story doesn’t fully wrap up at the end of the book. Of particular note, Prince of Killers ends with a significant cliffhanger. I don’t mind cliffhangers but if you are averse to that kind of ending you might want to wait until book two’s out so you won’t be waiting long to see what happens next. For me Layla’s redefined what a family of assassins looks like with this book. Fog City kicks off with some mind-blowing twists and I can’t wait to see what happens next.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!   Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

He's a libertarian, anarcho-capitalist. He hosts the biggest conference, Anarchapulco, for anarcho-capitalism. He's The Dollar Vigilante. Originally from Canada, hailing from Mexico. Jeff Berwick   Stefan: Ladies and gentlemen, welcome to the show, Respect The Grind, with Stefan Aarnio. This is the show where we interview people who achieve mastery and freedom through discipline. We interview entrepreneurs, athletes, authors, artists, real estate investors, anyone who has achieved mastery and examined what it took to get there. Today on the show, I have a very special guest out of the norm, Jeff Berwick. He's a libertarian, anarcho-capitalist. He hosts the biggest conference, Anarchapulco, for anarcho-capitalism. He's The Dollar Vigilante. Originally from Canada, hailing from Mexico. Jeff, good to have you on the show today. Respect The Grind, my friend. Jeff: It's a pleasure. Thank you. Stefan: Yeah. I really appreciate having a guest like you on the show, because we normally talk about like business and making money, and real estate. A lot of people listening to this show, they want financial freedom for themselves, and they're trying to make money. They're trying to invest, whatever that means. It's cool to have a guy like you on the show. We had a mutual friend of ours, John Sneisen, on the show a little while ago, and I love talking to guys like you, because we end up talking about the money system. We talk about freedom in the free world, free speech, all this kind of stuff. For the people at home who don't know you, Jeff, can you introduce yourself in your own words? Who are you, and why is this a relevant conversation for us to be speaking? Jeff: Sure. Yeah. Actually, it's a totally relevant conversation that's everything that I talk about. I've been doing that for about nine years now, since 2010, with The Dollar Vigilante, which is a anarcho-capitalist financial newsletter talking about how to free yourself. Not just financially, but in every way possible. Of course, for people that don't understand the word, "anarcho" means anarchy, of course, and that's a Greek word which means "an," without, "archy," ruler. I just believe that no one should have a ruler and no one should be a slave. I don't know why that's controversial at all, but that's the government indoctrination camps that people have had for about 12 years that most people have been forced into. Jeff: Then the capitalist part, a lot of people actually misunderstand that word, too. They think that what you have in the U.S. today is capitalism. There is a small part of capitalism still remaining, and that's why the U.S. is still standing, but it's mostly fascism, and crony capitalism, and what I call crapitalism. Really, when I say "capitalism," I just mean free market. I've been, and completely free market, so no government involvement whatsoever, no taxation, no regulation, no central banks, and no fiat currencies and things like that. I've been doing that for about nine years. Jeff: I also do a podcast called Anarchast. I've been doing that for about seven years, and it's grown quite a bit. It's nothing too huge, but it's actually spawned an entire conference now called Anarchapulco, as you mentioned. It's now the world's premier liberty and freedom event held in Acapulco, Mexico, every year. It's coming up in February 14th to 17th. We're expecting about 3,000 people, because the freedom, the idea of it is actually growing, believe it or not. I've been doing all that stuff for about, as I said, about eight or nine years now. Stefan: That's tremendous, Jeff. People like you, I really got to salute a guy like you, because it's not easy. It's not easy going against the grain. It's not easy speaking out about this stuff. It's not a popular table topic at the Thanksgiving table or the Christmas table. I remember when I was telling my family years ago about the money system at like at Christmas dinner or Thanksgiving dinner. Everybody got up and left. The average person doesn't want to hear about how they are enslaved. They don't want to hear about the money system. I remember years ago when I was 21, 22, I read a book called Atlas Shrugged by Ayn Rand, and that's the capitalist bible. The communists have Karl Marx, Das Kapital, and then the capitalists have Ayn Rand's Atlas Shrugged. It's number two most influential book in the United States. Stefan: Can you explain to the people at home, that's where I've first heard the word "libertarian." What's a libertarian? Because people, we're from Canada, or I'm from Canada, in Winnipeg, today, and people hear "libertarian," and they think libertarian is liberal, because it's L-I-B. They don't know the difference between the two words. What's a libertarian? Jeff: That's interesting you're up there in Winterpeg. I'm originally from what I call Deadmonton, so up in Canada. Stefan: Dude, that's the other Winnipeg. I'm giving that a gong. Bang. Just gonged it up. Deadmonton and Winterpeg. Jeff: Yeah, so the word "libertarian," I actually didn't even really know the word until about 15 years ago. It's become quite popular. It's become fairly popular since Ron Paul ran for president in 2008. Really, what the word means is, well, it's pretty simple word, "libertarianism." What it means is that if you're a libertarian, then you hold as one of your highest principles liberty or freedom. If you truly hold that as one of your highest principles, then you should actually be a anarchist, because an anarchist believes in complete freedom. It believes in the freedom of the individual that no one has the right to enslave and say they own another person. Of course, whenever you have a government, you're just born somewhere, and they go, "Well, you're ours now," especially in the U.S., where every baby born today in the U.S. has a quarter of a million U.S. dollars worth of debt and liabilities overhanging it from the government that it's supposed to pay off. Stefan: My God. Jeff: That's absolutely criminal and absolute tyranny and slavery. That's what we have in every country today, as well as Canada and every other country. A true libertarian truly believes that no one should be ruled or owned by anyone without their permission. Of course, there's a lot of people who don't mind being owned or being slaves. They're called statists, and if they want to do that, that's fine. I have no problem. As a libertarian or as an anarchist, do whatever you want. Just don't aggress against me. The only problem is, when they get these governments going, they always seem to include us and seem to think that, "Well, you are now owned by whichever government in whatever area you're in." I just completely disagree with that. Stefan: Yeah. I saw Jordan Peterson. You're probably familiar with Jordan Peterson, right? Jeff: Yeah. Stefan: I saw Jordan Peterson speak in the summer. He was speaking here in Winnipeg, Winterpeg, at the Burton Cummings Theatre, and he said something interesting that I thought something that I think people need to hear more often. He said, "The human race for most of history has lived under tyranny. We used to have monarchies. We used to have feudalism. For most, most of the human race, we've had tyranny, and for very brief times, we've had democracies or republics, but democracy lasts for about 250 years. Then it turns into a tyranny, usually, and then after that, turns back into a monarchy." Why do you think monarchies and tyrannies have existed throughout history, and why does it always seem to consolidate power like that? Why can't we just stay as a democracy or republic all the time? Jeff: Well, first of all, I'm not so sure about human history. I think most things we're told about history are lies, and so really, anything beyond a couple of hundred years ago, I really have doubts about what really happened. I really don't know what happened, but I don't trust anything that we're told by the media, or the governments, or the schools, which are all sort of the same sort of people running those sort of things, but what I understand happened is, a few hundred years ago, there was things like kings and queens, and they were doing that quite a bit. They were going around doing similar things that governments do today and say, "Hey, you were born here, so now you have to pay us a certain percentage of whatever you make," and that sort of a thing. Jeff: Really, a few hundred years ago, and it sort of seems to have happened in France, which is kind of interesting, because there's a bit of an uprising happening there again right now, is a lot of people said, "This is crazy. Just because you're born, this whole idea of kings and queens is so insane." I love the Monty Python, I think it was in the Holy Grail one, where the king's walking around, and he's like, "I'm your king." They're like, "You're who?" He's like, "I was born of this mother," and everyone's like, "What?" He's like, "I found a sword in the lake, and therefore I'm your king." They're like, "You're crazy," but for whatever reason, people kind of fell in line with that. Jeff: Of course, a lot of these monarchies were really tyrannical, and they would really, if you didn't pay them, they would kill you, that sort of a thing. That's very similar to governments. A few hundred years ago, people kind of woke up from it, and they said, "Well, this is stupid." The people who were in control at the time really realized they're going to lose a lot of power, and so they came up with an absolutely ingenious idea. That ingenious idea was democracy, which is a totally heinous, evil system of mob rule. If you have 51% of people decide that legally they can kill the other 49%, then everything's fine. Jeff: It's absolutely insane and just keeps people battling each other, but it's absolutely ingenious, because they've managed, through the government indoctrination camps, and through the media, the mainstream media, television, propaganda programming, to tell people that, "Oh, when you have a democracy, then you are the one who rules yourself, and you get to rule yourself by voting once every four or five years. You get to tick a box," and then some guy goes somewhere, and he makes decisions about what you're going to have to give up and how much they're going to extort you and things like that, but it's absolutely an ingenious idea. It's worked now for a few hundred years, and people have really fallen for it, but they're starting to wake up to it. That's what we're starting to see across the world, really. Jeff: We're starting to see that in France right now. Again, they're starting to realize, "This is absolutely insane that we have people ruling us without our permission, and taking our money, and things like that." Even Donald Trump, in the U.S., was to an extent an awakening of people going, "This system is horrible. We've got this total political class that is totally ruling us and just totally enslaving us." Jeff: What they thought was, "Well, we have democracy, thank God. We have democracy, so we can elect someone else," so they elected a kind of a bit of an outsider, Donald Trump, who's best friends with the Clintons and has been involved with central banks and with the Bush family for decades. His family's been very involved with the Bush family, so he's been very involved in the political class, but he came in as sort of an outsider, and you kind of see a lot of people saying, "Oh, he's an outsider, so he can fix things." He's not an outsider whatsoever. It's another sort of ruse in the whole democracy game, but really, that's what we've got today. Jeff: Now, what we've got at The Dollar Vigilante, I cover how bankrupt all these nation states are, how the central banks are printing money until we're going to be, hit hyperinflation very soon, so we're very near the end of this sort of system of these big nation states, of these big welfare states, warfare states, Big Brother nanny states, where everything is controlled, and regulated, and extorted, and taxed, and that sort of a thing. It's all going bankrupt right now, so even if people didn't wake up to what I'm talking about, we're still going to go through a massive amount of change in the next few years as all these systems all go down because they're all bankrupt. Stefan: Yeah. Well, there's a ... Man, Jeff, you said a mouthful there, man. I don't even know where to start, but I'm going to try to weigh in on what you said there at the end. Now, I wrote a book here called Hard Times Create Strong Men. I'm holding it up here for the camera for the people at home, and the cycles of history, as I understand it, goes like this. Hard times create strong men. Strong men create good times. Good times create weak men. Weak men create hard times. That whole cycle takes about 80 years, and every 80 years, there's a major war, a major crisis, a major reset. 80 years ago was World War II. 80 years before that was American Civil War, and you can trace this back in history. 80 to 100 years, every 80 to 100 years, is a major reset. Now, if you trace that out to the future right now from World War II to now, 2020 is the next "hard times create strong men." Stefan: That's what the book's about is, the men are becoming weak. When men become weak, the backbone of society falls apart. The family falls apart. The churches and the freedom of that falls apart, and what we end up with is some sort of major crisis. Would you say something like that's coming up? Jeff: Oh, absolutely, and I think those cycles are very true. If you just look at anyone who's like a rich kid, so his father most likely worked really hard his entire life and amassed a fairly large fortune, and then the kid comes along, and he's just pampered, and he never does anything. He never learns how to do anything. He never has to learn anything about life, and they usually become idiots, and they actually end up usually wasting or losing most of their money. This is a very natural sort of a cycle that can happen if you're not smart, if, as a father, if you make a lot of money, you don't just give it to your kids. That's absolutely ridiculous. Talk about a really great way to destroy your children, but the big problem with that cycle that you just mentioned that's been going on now for centuries is the government. Jeff: When you get the government involved, it's not just people who are destroying themselves through the cycle of people having to have hard times to get better and actually learn skills and work hard, and then they get soft afterwards, and then their kids get really soft and that sort of thing. That happens all normally, but when you add the government into it, it gets way worse, because then what, that's exactly what we're seeing today in a place like the U.S., which used to be quite capitalist. It has been fully capitalist, really, since its inception. It hasn't been, definitely has not been capitalist since 1913 when they first put in the Federal Reserve and the income tax acts in the same year, which is no coincidence whatsoever. It's been kind of a mix of the socialism, and communism, and fascism since then. Jeff: About what you've seen because of the capitalism, because of the free markets, there was quite a bit of free markets in the U.S. There isn't any more, but there used to be quite a bit. You build up all this wealth, and when you have a government, it always seems to skew to these people going, "Well, now that we have quite a wealthy place, we should be quite giving." Yeah, that's great. Give, but what they're talking about is, the government should steal money from everyone, extort everybody, and then give some of it to some people, which is absolutely heinous, and evil, and destroys everything. Jeff: Even the welfare system destroys the people on welfare, but as I was mentioning, like that whole cycle would happen probably quite normally unless people start to wake up and realize what they're doing, but the fact that we have governments today makes it so much worse, because that's what we're seeing in the U.S. You even see communism is really catching on in the U.S., because you've got all these pampered little kids. They sit there on their MacBook Pro at Starbucks ranting about how evil capitalism is and saying they want communism, and they don't even look up the last 100 years of what communism has brought a lot of places, like the Soviet Union, or Cuba, or Venezuela, and places like that. Jeff: They just, because they're so soft, and they've never really done anything, that's why they call them little snowflakes and things like that, and they become social justice warriors. Really, they're just non-player characters, NPCs, but yeah, the big problem with that whole cycle is government. If we can get government out of the way, then you'd have families destroying themselves over time over and over and not realizing the problems that they keep creating for themselves, but they wouldn't force it all on the rest of us through government. Stefan: Yeah. Wow. I mean, this is some really good stuff, and the snowflake thing, the snowflakism's a reason why I wrote Hard Times, because I had some of these snowflakes in my company. I have a company. I got 13 employees, and these little snowflakes were crying, "Oh, you're mean, and I don't love this. This isn't my dream job, and you make me feel like a piece of shit," and I had people showing up late. Just snowflakism all day, and I said, "Where does this come from? Where does the snowflakism come from?" I started writing this book Hard Times, and it's interesting, because what you said is absolutely true. Stefan: We've had some communist subversion come in from the Cold War into our schools, into our churches, into our militaries, everything, and we got this virus in our brain that thinks that communism is going to save inequality, but in history, communism has never worked. It has never worked once. It ends in massive, massive killing and massive death. There's something like 100 million people slaughtered in the last 100 years with communism. It's something brutal. It's the biggest cause of unnatural death, and every 80 years, we think it's going to work somehow. Somebody somewhere's trying communism. Stefan: As an extension, I've been studying communism, I was watching a show with Stefan Molyneux on Freedomain Radio, and he was talking about how feminism actually spawned out of communism when they started talking about equality, and men and women are equal, and next thing you know, in communist Russia, in 1917, when they switched over to communism, you had all sorts of major problems, where there was one crazy stat was, more babies were aborted than were born. You think about that, it's just a big, crazy, evil system. Why do we get this idea that we think that communism's going to save us from our own poverty? Like why does that idea keep coming in every 80 years into different societies around the world? Jeff: Yeah. That's a good question. I wish I knew the real answer, because it makes no sense. Obviously, these people don't look at actual history. As you pointed out, there's never been one ... It's not like there's been one that really worked out well, and they're like, "Oh, we screwed it up a few times." It's like every single one turns into disaster. It actually makes total sense why, because of human nature. For someone like yourself who's read books by Ayn Rand, you kind of understand the individualist sort of a thing, and that people will always do what's in their best interest. That just makes total and normal sense as human being. When you have this system that comes in and you say, "Okay, the guy at the top decides everything that we're all going to do," you don't keep anything from your work, so that makes it so a lot of people don't really want to work anymore, because why would you work if all the incentives go away to ... Jeff: I don't know about you, but when I do work, it's because I know I'm going to get something from it. I'm not just doing it because for no reason whatsoever. A lot of these people, especially ... Well, what's really happened in the West is that they've really pumped it up in the government indoctrination camps. That's why I say to people, "Get your kids out of the government schools. There's nothing that can be worse than that than having government actually teaching you ... " Not teaching, actually indoctrinating your child for like 12 of its most important years of its building of its sense of self, of its intelligence, of everything. Even Vladimir Lenin, of all people, said, "Give me your child for four years and the seed I plant will never be uprooted." Jeff: It starts a lot there, and then you go home in places like the U.S., or Canada, or a lot of places, and you turn on the television programming, and it's called programming for a reason. You get pro-cops, and pro-presidents, and, "The government saved us today," and turn on the news, which is total fake news. It's just government propaganda, and they're like, "Well, we saved this today," and all that sort of stuff. With the cycles that you're talking about, and we're in the snowflake cycle now of sort of this millennials that have never seen anything hard their whole life. To them, the hard thing they've seen is like when there's a long line at Starbucks or something like that. Stefan: No Wi-Fi on the plane. There's no Wi-Fi on the plane today. Darn. Jeff: Yeah, like that's the hardest times they've seen. Because they've gone through this indoctrination and that they're really, I actually stay away from colleges and universities, because it freaks me out to hang around, like they're all zombies, and they're the stupidest people I've ever met in my life. They're all indoctrinated and programmed. You go there, and half the classes are talking about communism and socialism, so they've got them in this sort of thing, and they're all going out there now. We've seen that ... What's that, there's that U.S. politician, some young girl, is just complete and total moron who's just got selected or elected into Congress. It's called Congress because it's a con game, and it's called the Constitution because that's also a con, and all that sort of stuff. Jeff: You've got those people out there pushing this stuff, and these kids just go out, and they think, they don't know anything better. It's very unfortunate, but that's why it's really important that we continue to push out what we push out, which is more free market stuff. A lot of people do catch on to it. It's not as bad as it seems. The worst place that it really is in the world today is the U.S. They've got everyone ... Not everyone, but most people, they're so indoctrinated, and so brainwashed, and so propagandized, but you go to a lot of other places like Mexico here, and a lot of people are pretty free market. They don't like government and things like that. That's why they make Mexico look so bad on the news. That's on purpose, because it's a lot more free market down here. Stefan: It's amazing. I mean, you moved to Mexico. I have this prediction that Russia right now is a freedom-growing country. They're getting more freedom over there. It's like the 1950s U.S. over there, and then over here, it's like we're a freedom-losing country in Canada and the U.S. It's interesting with, you're talking about the universities being scary. When I get a stack of résumés, and I'm hiring, I throw the ones with degrees in the trash. Yeah, they don't- Jeff: Yeah, me too. Stefan: The people can't think for themselves. I remember I went out with this 18-year-old girl, and she wanted a job, so we went out for lunch, and I said, "Okay, look. What do you want to do?" She goes, "I want to start a social media company." I'm like, "Great. Start it." We're eating lunch. I said, "Great. Start it." She says, "Well, I'm in the business school, and I'm going to get my MBA, and I don't think I can start, because I don't know how," and I said, "Well, go google that. Just start." "Oh, I don't think I know how. I'm not qualified." The school system literally disabled her mind from figuring out how she could just start a social media company. Stefan: I mean, I got some guys running my social media. They're 18, 19 years old, and I just met them at a restaurant. Boom, they're banging out my social media like crazy, doing a great job, but this same girl in the government indoctrination camp, as you say, the universities and the schools, can't think for herself. I also think it's interesting in the colleges and universities right now, the number one read book on economics is Karl Marx. That's just like, that just doesn't make sense. Why don't you tell me a bit, Jeff, why does Karl Marx as the number one economics book not make sense? Jeff: Oh, my God. First of all, he knows nothing about economics. He was a homeless guy who had no money, and he wrote a ... If I was around when he wrote the book, I would have given it a few minutes, or even maybe a few days, maybe even a month or two, of thought, because it sounds really good. Right? Like what is the communist sort of slogan? It is, "Give to-" Stefan: Seize the means of production? Jeff: No, but they have this slogan like, "Someone's needs ... " Stefan: Oh, "To every man's need," or, "To the best of his ability and every man's need," or something like that. Jeff: Something, but basically what it's saying is ... See, that's how stupid it is. I don't even memorize the stupid quote, but basically, it sounds nice. It sounds like, "Yeah, if people can't do things, then you help them." It's like, "Yeah, sounds great," but the way they're talking about is, you have this giant government. They come around. They steal things from people, and they decide who gets your money, essentially, and things like that. Yeah, and it's shocking that ... It's really mostly caught on in the U.S. Like obviously, if you go to the ... You brought up Russia. If you go to Russia, no one wants to read Karl Marx. They'd probably burn that book if they saw it, just because they'd be so angry at it. Jeff: Anyone who's actually lived through communism, a lot of the old Soviet Union, the Eastern Bloc, Poland, and a lot of those places, even Germany to an extent, they still remember a lot of that. That's all you need to know about communism is live through it, and you realize it. That's one thing that I always thought that's funny is, you have all these people like Bernie Sanders and all these people, and they're so pro-communism and socialism and all these sort of things. It's like, have you ever even just gone to Venezuela even for a weekend? Because I was there like a year and a half ago, and it was pretty bad. Jeff: I remember being there about 15 years ago, and it was really nice. In fact, you can look up Venezuela back in the '60s and '70s. It looked just as nice as what you see in the videos of the U.S. People got around in nice cars, looking all nice. Everyone's looking good and happy, and they have lots of food and all that sort of stuff, and now it's just a complete and total disaster, so ... Yeah, you have some people still ... It's mostly in the U.S., though, I have to say [inaudible 00:23:04]. Jeff: I meet a lot of people from the U.S., and they say, "Man, this whole world's going to hell." It's like, actually, it's not too bad. Most of the world is pretty good. It's really the U.S. is like, and Canada is almost just as bad now, and when you go to the universities, as you pointed out, and I do the same thing, I have only hired one university graduate ever, and it turned into the biggest disaster I've ever had. He was actually a producer at CNBC, I hired him in 1999 to head up a video department of a internet company I had, and he was a total disaster. He was an MBA, and I had all the, all that stuff, and I ended up having to pay him out like two years' salary to get him to leave, that sort of- Stefan: Oh, my God. Jeff: But yeah, so I just stay away from the universities. As you pointed out, if I ... I've got a number of businesses myself, so if someone's interested in working with us, I'll ask them what they do, and if they go, "Well, I just spent the last eight years in university," I'm like, "Well, you don't make very good decisions, do you? You [inaudible 00:24:00]-" Stefan: Bro, I'm going to give you a gong for that. Boom. I want you to instant replay that for the kids at home. "If you're hanging out in university the last eight years, you don't make very good decisions, do you?" Tell me why that's a bad decision in 2019. Jeff: Well, I'm sure there's probably a couple courses you could take in college that make some sense somehow. I've never seen them, though, but I ... There must be a couple, but the reason that it makes no sense in 2018, 2019, is because we have the internet now, and all information is on the internet. You don't have to pay $100,000 a year to go sit in a room with probably a unionized teacher who's never done anything his whole life, that's why he's a teacher, he doesn't know anything, and sit there with a bunch of other idiots like you, because you don't know anything, they don't know anything, and learn about socialism-type stuff pumped into you. It's a complete and total waste of time. Really, the best- Stefan: You mean it's a virgin sex therapy class, so the guy teaching, it's a virgin, but he's teaching sex therapy to everybody? Jeff: Yeah, that's one good way to put it, but yeah. It's just a waste of time. I think trade schools or something, where if you're going to become a mechanic, so you have to work on cars, so you can't really do that over the internet, I think that makes some sense, but 90-percent-plus of what you go to college for is just a complete and total waste of time that you could just totally learn much better stuff on the internet. It actually just came out, I don't know if you heard this, but Google and Facebook just said that they've removed university education as one of the requirements to work there. I think they're really slow and late to do that, but I think they're starting to realize, it's like, "Man, the people we're getting from the schools are just brainwashed idiots, whereas the young guy who's sitting at home just hacking away, and going on the internet all day, and figuring everything out, those are the kind of guys you want." Stefan: Yeah. I got a policy in my office, and when people come to me and ask for stuff, I say, "Google it, or handle it." Those are the two things, handle it, google it. Google and ... I think it was Google, Apple, Facebook, they don't need degrees anymore. I think that's been going on for some time, but it's an official statement now. Right? That's like super, super official. Jeff, let's go back to collapse of society and things like that. One thing that's common in history, and I've studied it over and over again when these collapses happen, it's usually, the people can't buy bread. The nonsense can keep going on. The ... Stefan: I've got the numbers in my book here, Hard Times, about minimum wage, and minimum wage in 1968, indexed to gold, is 103,000 dollars U.S., so you work at McDonald's, you made one cheeseburger, one hamburger, French fries, Coke, and a milkshake, you made 103 grand in purchasing power back then, indexed to gold. Same guy today making a cheeseburger, hamburger, French fries, well, he has to make 150 items down at McDonald's. They got a crazy menu. Stefan: Same guy at McDonald's makes 13,000 a year, so he's lost 90% of his purchasing power indexed to gold, and this shenanigan with the money system where the banks and the government rob people through inflation every year, and then suddenly, at some point, it keeps going, going, going, going until the average man can't buy bread. That's when the Russian Revolution happens. That's when the French Revolution happens. Why does that pattern keep happening over and over again? Jeff: Well, first, let me just mention that the reason that these jobs have gone so far down in value is because of the central bank. It's because of money printing and inflation, and that's why you pointed out those numbers in inflation terms. You have a lot of people out there today who are like, "We need to raise the minimum wage," which is, what you're saying is, "We need these people who extort us, called the government, to go out with guns and force businesses to pay us more because we can't afford to live." Well, the reason you can't afford to live is because you've had most of your stuff stolen from you by the central bank, and the central bank, by the way, is a tenet of communism, and that's why I say the U.S. is nothing even close to capitalism today. Jeff: Actual communism has already destroyed most of these people. You ask about revolutions, and yeah, it seems that people, this is one thing you can say about anarchy, a lot of people think about anarchy, "Well, if there was not government, it'd just be chaos, and horrible, and everyone would just kill each other." It's actually not true. Your average person, and this relates to your question, your average person just really doesn't want to do too much. They want to have a nice little life. They want to have a family or whatever, or they don't, but they want something nice, and that's about it. They don't want to go out and rock the boat too much. Your average person just does not want to rock the boat, and that's what ... Jeff: That's one of the problems we have today is, we have the statist system, and most people are just too scared to change it, but it appears, at some point, when you finally run out of even just food, and you can't even eat anymore, that's when finally people start to wake up, and stand up, and demand some sort of change. When I say demand, the problem is, they're demanding from the government change. What they should really realize is, the government caused it, the central bank caused it, and just break away from this system and stand up and become their own person and not be a slave to the systems, but yeah, it's unfortunate that your average person, for whatever reason, will wait until they're basically starving before they actually face the real problems in the world. Stefan: It's interesting in history, I think Putin kicked out the central banks. Is that right? Jeff: I'm not sure if Putin did, but the ruble basically collapsed. I don't think they had a central bank, definitely, at the start there. Stefan: Well, I've heard Putin's kicked out the central banks. I think it's interesting is, Hitler did that back in the day. I guess Germany was so poor, and they were so messed up, and they couldn't make their war reparation payments. They just couldn't pay, and that's how World War II started is, a bunch of people, super poor, couldn't pay their payments, boom, world war starts. It's interesting, because somehow, in the system, the political system, they go right versus left, and the right versus the left, and the left versus the right. Really, it's the same kind of thing. Nobody points the finger at the central banks. Stefan: One thing I love about America that still stands is, there's 300 million guns in the States and 300 million people, and they keep that gun amendment in there because they know that tyranny's going to come at some point. They left that in there, and if people can't buy bread, or they're really hungry, that's where those 300 million people with guns are going to rise up. Do you think we're going to see something like that in our lifetimes? Jeff: Yeah, definitely, because the U.S. is going to collapse in the next few years. It's not going to be decades, because it's so bankrupt. We have 22 trillion dollars' worth of debt now, so we're basically ... I said when I started The Dollar Vigilante that the U.S. dollar will collapse by the end of this decade, so we've got about a year left. I think we're pretty close to on track. That's how close we are to the end of this system. Yeah, we're definitely going to see collapses anyway. As far as people in the U.S. having guns, I think all people should have the right to defend themselves, obviously. I don't think anyone should be able to say, "You can't have this," if you're not hurting anyone else, and that's what government does, of course. It's very good. That's the only thing left in the U.S. that is keeping it from being complete and total carnage is that the people still can protect themselves, so the government has to be very careful about how they enslave everyone, but they've done an incredibly good job of enslaving people. Jeff: When you think about how the U.S. started, it started over the Tea Party, where it was a tax from England on tea, and that was it. It wasn't a tax on everything else, income tax, and capital gains tax, and smoking tax, and hotel tax, and food tax, and all this sort of stuff. It was just a little tax on tea, and that started the so-called American Revolution. Now you have people in the U.S. today where you have taxes that are over 50%. It's probably closer to 60 or 70% when you add up all the taxes, because literally every single thing in the U.S. is taxed today, including death. Death has a tax, and so when you die you get taxed. You still don't have people wanting to revolt. It's because, again, people are fairly, if they have a decent life, they don't tend to want to change things too much. You look at the U.S. and your average person, even poor people have a television. They probably even have a car. Even poor people have cars in the U.S. Jeff: That's how much free markets, even the poorest people are still ahead of a lot of other people in the world, and so because of that, they don't really want to have a revolt or anything like that. Plus, they don't even ... Because of all the years of government indoctrination and all the war propaganda about how they're trying to save the world by spreading freedom by bombing the entire world in the War on Terror, war of terror. It's absolutely insane, but your average person just doesn't seem to want to even break out of this system. Jeff: What's going to probably happen is, that system's going to collapse on its own because of all the debt and go into hyperinflation. Then hopefully, and you brought up about how Russia's become much more free market now. That's what happens. The same cycles that you mentioned before when you have countries, they usually start off quite small and poor. Even the U.S. was like that when it first started. Because it had a lot of freedom, it becomes quite rich. Then they get soft because of that and because of government and statism, they start doing socialism and all these sort of things which start to destroy everything. They start putting kids into the government schools and all that, and they get worse and worse until they eventually totally collapse, like the Soviet Union. Once it has a total collapse, then you can actually have free markets again. The U.S. actually, once this collapse happens, and after a few weeks or months, and that's sort of what happened in the Soviet Union as well, it takes a little bit of time, like weeks or months, definitely not years, then you can start to rebuild immediately again with free markets. Jeff: We've seen how the free markets, if you just allow people to be free, you just have to look at places like Hong Kong. That was a fishing village like 200 years ago. Look at it now. I don't know if you've ever been there. It's amazing to even go there. Singapore, even 100 years ago, was a fishing village. It's now one of the most luxurious, wealthy places in the world. Dubai was just desert. They just started doing like low-tax, no-tax sort of stuff, and all of a sudden, there you got like indoor ski parks in the hot, 150-degree desert. Once you have like all this tyranny, it will eventually collapse. Then once it collapses, you have freedom again, and then things take off again. Jeff: Really, that's the whole point of what I do at The Dollar Vigilante is, that's our actual tagline, which is, "Helping you to survive and prosper during and after the dollar collapse," because if you can hold on to some of your assets, and if you can get through this collapse that's coming, we're going to go on to amazing, prosperous times again, but if you have no assets, you'll have to work a lot harder to get back up, but if you have kept some of your assets and things like precious metals or cryptocurrencies, once everyone else gets wiped out, and all the banks close, and the currency becomes worthless, you'll be one of the richest guys around, and then you can start rebuilding the new free market. Stefan: Yeah. There's two cycles that are coming to an end. I wrote about this in my book, Hard Times. One is the 2020, which is that 80-year cycle of war. That's an important one to watch. Hard Times Create Strong Men. Then the other one is the 250-year cycle of democracy. Democracies only last about 250 years, so if the U.S. was born in 1776, it's going to be dead by 2026, so somewhere between 2020 and 2026, we know there's probably going to be an end of democracy, probably usually goes democracy into tyranny, and then tyranny back into monarchy usually is what happens. We'll see something happen. Do you think it's going to go back to tyranny and monarchy, or do you think it's going to go just to open freedom? Jeff: Yeah. A really good question. I don't know how it's going to play out. I could definitely see the tyranny part coming after this. What will likely happen, and probably be Trump will be in, his regime will be in as this collapse happens. As everyone's gets wiped out, as the banks close, as it's complete, way worse than 1929, Great Depression, someone like Trump will become sort of like Hitler-like in that sense, in that he will be the strongman who will lead the country out of this. Because of that, we're going to need more laws, and of course, Trump has been pro-asset, civil forfeitures, having the police just take whatever they want. He even came out recently and said that he's okay if the cops go and just take everyone's guns and then figure out if they did the right thing afterwards and go to court in that afterwards, so no due process and things like that. Yeah, I could totally see that we have this collapse in the next couple years. Jeff: It leads into a very sort of like Nazi Germany like sort of like tyranny type thing, and perhaps war, because the U.S. does have a massive amount of military just sitting there, and of course, if you're desperate, and if you're broke, and if your people are all crying out for something to be done, and of course, what do they always say on the news, the television programming? "Well, it's always Russia. Russia's always messing with us." Russia's not doing anything to the U.S. whatsoever, but they've been putting this into place, and they also mention China a lot. Yeah, they'll probably go into some sort of major war at some point. The key for people like us will be to stay outside of it and let them all go through this, again, if they want to go through this again, which is unbelievable. Jeff: There's lots of stories of people surviving through all of these, World War II, World War I, the Great Depression, and coming out way ahead afterwards, and even surviving quite well through it. A lot of them would go to places like Argentina or whatever for a few years, wait till all the craziness dies down with their assets and things like that. That's really the key, and to me, it's, we can't change everyone else. I wish we could, but we can't. Jeff: Actually, I don't wish I could. That'd be a huge responsibility, to change everyone else, but I wish that they would be a bit more able to see what's going on, but if they can't, really all that's left for us to do is to take care of ourselves and to keep spreading this information the ways that we can do it, but if they're going to go ahead and destroy the whole world with their statism, and their craziness, and their communism, and socialism, and fascism again, then it's really just up to us to survive and prosper through it and then try to be there to help rebuild once they get through doing it all again. Stefan: There's two interesting things that come to mind when you say that. There's the Hitler-Trump connection, which I think is super interesting. There's two things I want to allude to. There's the Hitler-Trump connection, and then there's another one, an Abraham Lincoln and Trump connection. When you look back in history, so if we go back 80 years to World War II, Germany was one of the most advanced civilizations on the planet, probably actually was the most advanced in science and medicine. They were so broke, they were so poor, they were so hungry, they were so messed up that the Nazis became popular, because Hitler was offering them a better life. He said, "Look, here's a better life. We can have a better way." People got behind that, the most sophisticated, probably, society on the planet went into absolute terror at that time. Stefan: I think there's a similar thing going on in the U.S. You've got a huge amount of people on food stamps. People are poor. People are pissed off, so they elect a strong leader. It's not ... It's interesting, like if it wasn't Hitler back in World War II, it probably would have been somebody else leading them, because the people were so poor and so messed up ... I like what Jordan Peterson said in the summary. He said, "You don't have an idea. An idea has you." That idea had Nazi Germany. I think there's a similar idea in the Brexit right now. There's a similar idea in the United States, and then that's the 80-year cycle. Stefan: If you go back 80 years before, you got the Civil War, the American Civil War, and Abraham Lincoln got shot. It's interesting, because Lincoln was a guy that wasn't totally popular with half the country. He got assassinated, and those things are all kind of floating around. You got a Trump, Trump-Hitler-like ruler there. I mean, I actually like Trump, personally, but at the end of the day, there's a sentiment in the country and a feeling around that that's Hitler-like, and then there's also an Abraham Lincoln kind of feeling where do you think he could get assassinated? Jeff: Look, I think it's possible. I think most of those sort of things, they're all actually orchestrated. JFK, for example, I believe that was Lyndon B. Johnson and the CIA who took him out. Ronald Reagan, that was the first Bush, the one who just died, George W. Bush, or sorry, George Bush, who was behind the assassination attempt, so-called assassination attempt, on Ronald Reagan. It's usually like an inside sort of a thing. It's really controlled. It's really theater. They actually keep all these things, including Putin, including little Kim in North Korea. They're all controlled by the same people, and it's just this big theater to keep people just mesmerized and watching their CNN and, "Oh, what did Trump say today," and all that. It's just no different than people in North Korea like, "What did little Kim say today? What are we supposed to do today?" Jeff: That sort of a thing, but anything is possible, but it is pretty tough to assassinate the president, as an outsider, but as an insider, it's not that hard, but they also seem to have some sort of weird like almost like protection around them. Like even George W. Bush, when he was in Iraq and the guy stood up at the media thing, and he was very mad, because Bush had been destroying his country and killing his family and all that sort of stuff, and he threw one shoe, and Bush just did the little dodge and just missed him, and then threw another shoe, and he just ... It's like, I don't know what it is with these people. They're kind of like, I don't know what it is, but it seems like he can't really get to them that way, not physically violent sort of thing. I think the only way we get rid of all of this is for people to wake up and realize that these people don't own you, and start to move away from these systems, and these people just go away and have to get real jobs. Stefan: I think one of the problems with human nature and people, I mean, you were talking about human nature and communism, where human nature doesn't work inside of communism, and then there's also another side of human nature, which is, I think humans have a hero worship, innate hero worship ability where we see someone, we see a leader, and we just want to worship them, and we want them to handle our problems. We want to have a personal Jesus. We want to have somebody we can just give it all to. Somehow, that's going to be the easy button. It'll all be solved, and then we don't have to think or deal with anything. Would you say that's true? Jeff: Oh, absolutely. That's exactly what government, it really is. That's what government always does. You look at every election. They come up there, and they give all these promises. "I'm going to solve this for you. I'm going to solve that." They never solve anything. They're just extorting you and destroying everything in the process, and making everything worse in the process, but yeah. That's absolutely the case is, your average person just won't take responsibility for themselves and just say, "I don't need this person to run this entire country for me. I can run myself," and that sort of a thing. Of course, it gets a little interesting how that would all, we've been in statism now for hundreds of years, so to actually break away from it's going to be difficult. Jeff: That's actually why we're starting up numerous sort of countries across the world now, so we've started Liberland in Europe, which is near Croatia and Serbia, which is a new sort of anarcho-capitalist country that's just being started, and there's some few others working on buying some islands, and we're going to start some totally anarcho-capitalist free sort of places there. We're also seasteading, so we're trying to start up in the ocean, start up our own little, what you call countries. None of them are really like countries, because there's no real government, but it's a place that we're going to start up that it's going to be completely free. Then through that, hopefully we could show the world, because they've never really seen it, what life would be like in a true free market. Jeff: If, all evidence seems to point to when you have a totally free market that it's incredibly good for most people. It just increases the wealth dramatically, as we've seen, as I pointed out, in places like Hong Kong, Singapore, Dubai. Whenever you have a lot of freedom, everything gets a lot more prosperous. The only sort of question a lot of people have is, "What if you have total freedom? What would happen?" We don't really have any good examples for that yet, so we're hoping to start do that in the next couple of years and try to show the world the light that, really, this governmental sort of statism system with central banks, and all these sort of things, are just absolutely terrible. The best thing for all humanity is to get rid of those sort of things and not have a belief in their authority. Stefan: Sounds like a page out of Atlas Shrugged right now. You got all the productive smart people wanting to go start their own country or start their own island. This is, it's just human nature. It's all written down in the book. It's all happened before, and here's a thought, Jeff. I don't know if you thought about this. At some point, there probably was some nice, true freedom in the Wild West, maybe, Wild West America or some place, and then at some point, the people organized themselves. At some point, there's a government. At some point, there's a king. At some point, there's a good king. He dies, and then you got his son, the bad king. Stefan: Do you think we've had freedom in history at some point, like true freedom, and then it just got consolidated into power? Because it seems to me that whether you look at a market like a real estate market, or you look at a Monopoly board, or you look at anything in life with humans, it seems that there's like always a consolidation going on. There's a consolidation at some point where somebody just ends up taking over, and we just end up in that over and over again, and the dominoes fall down at some point. We reset. Do you think we can actually exist as free people, like truly, or do you think someone's going to seize power at some point? Jeff: Well, the thing is, if you have enough people who actually believe that freedom is the way to go, and they want to do that, then no one can seize power, because there's nothing there to seize. You pointed out rightly that over history, it appears that people have always been okay with giving away their power to someone else and hoping this guy takes care of them all, and that never works out for the best, just like communism, it just never works out well. Jeff: Yeah, that's actually been the case over time is that people seem to have always sort of gravitated into these sort of things, but at the same time, when you think about life even today, we actually live in a state of complete anarchy right now. It just so happens that there's a lot of governments on earth which you can just consider to be criminal organizations who are stealing and extorting people, and kidnapping people, and forcing them to do things they don't want to do, but we actually live in a state of anarchy. Jeff: Your average person, actually, every single day of their life, pretty much lives in anarchy. When you're in your home, or you're talking to your friends, or you go to work, that's just anarchy. That's just day-to-day life, and there's no one there telling you what to do, except for a street cop or whatever, a road pirate who might try to extort you if he thinks you're going a little too fast over a arbitrary speed limit or things like that, but generally kind of already live in anarchy. Really, the important thing to understand is that the word "government," what it really means, "govern" is, the word "govern" comes from the Latin [Latin 00:46:24] which means to control, which makes a lot of sense, and the word "ment." Jeff: There's a lot of different sort of where that came from, but I lived here in Mexico, Spanish, [Spanish 00:46:34] is mind, so really, government is mind control. It's controlling people's minds to make them believe that this thing has authority over them and that it's sort of taking care of them as well. This is where we get into Stockholm syndrome and things like that, where people actually begin to really adore their kidnapper, the person who has basically kept them enslaved. I see [inaudible 00:46:56]- Stefan: I wanted to give a gong. At some point, you got to stop for me to give you a gong. I didn't know that "government" meant mind control. It's really interesting, because if you control the information, you control the thoughts, and if you control the thoughts, you control the stories. You control the stories, you control the beliefs. If you control the beliefs, you control reality. It's almost like ... In Hard Times, I talk about we almost live in a 1984 future from George Orwell, and some of it's like Brave New World, Aldous Huxley, which was Orwell's mentor. We got half of our stuff is the American Aldous Huxley Brave New World future with orgies, and synthetic music, and all these women with narrow hips that don't bear children anymore, and we have alphas, and betas, and gammas, and deltas and all that stuff, and epsilons. Stefan: Then the other part of our world is like the 1984 future where there's three gigantic powers that are always at war with each other, and it's like a Stalinist future. What do you think about those two books right now, Jeff, like 1984, Brave New World, and what we got going on right now? Jeff: Yeah. Both those guys, both, I think they went, both went to Oxford or one of those major schools. They hung out with the same people like the Bush crime family and all those, so they hung out with what you could call the elites, or some people call them the Illuminati or whatever words you want to put to these sort of secret societies that mostly sort of are in these schools like Oxford and stuff like that. They were actually good friends, as you pointed out, and it's really amazing that that long ago, what is it, like 60, 70, 80 years ago, they wrote- Stefan: It was 1945- Jeff: ... these books. Stefan: ... I think. It was like right after World War II the books came out. Jeff: Yeah, so I can't do the math. I went to government schools, but 70 years ago, whatever it was, and they've really just roadmapped the exact both ways that we're going. Actually, they're both happening at the same time. The Aldous Huxley, Brave New World, that was a lot of bread and circuses. The people would be too dumbed down, which we're seeing, through fluoridization in the water, through all the government indoctrination camps, through the television programming, all that sort of stuff. People are just watching the Kardashians and all that. Jeff: The sports, so the sports ball games, and that sort of thing, so people, that's what Aldous Huxley was saying is, people would be too dumbed down and too into these things like sports and entertainment to even notice that they're enslaved. That's what we have today, especially in the U.S. Then on the other side, there was Orwell went the other way with a bit more it's like a hard, top-down dictatorship. You can't say anything. Everything's the opposite of what it means in political speak, which is what we have today. You brought up about how there's these certain sectors of the world that always at war. East Oceania's always at war with whatever the other one was. That's what we have today. It's like, who's at war with who? This War on Terror, it's a war on a feeling. It's a war on, it's like terror is a feeling. It's like, "I was terrified when I saw that. We need a war against that." It's like- Stefan: Well, we got the- Jeff: ... "Who are you [inaudible 00:49:47]" Stefan: ... War on Drugs which doesn't work. We got the War on Terror that doesn't work. You got the War on Cancer that doesn't work. You got all these wars. They keep just funneling money into a couple dudes' pockets, and the War on Drugs makes drugs worse. The War on Cancer makes cancer worse. The War on Terror makes terrorism worse. It's pretty scary how those things just simply don't work. Jeff: Yeah, and it's all by design, like the people who really do these things know this is what's going to happen. It's just sad that people keep falling for it, but people are slowly waking up thanks to the internet. Yeah, I even saw like, who's that blonde, fairly not attractive, woman on U.S. TV who's like a really mean, nasty sort of ... Anyway. She just came out, and she just said all these wars are just stupid. They're just like, like we shouldn't be doing them. She was like a total war sort of a person. This just came out. Jeff: People are starting to wake up, but the biggest issue is, they don't know what the answer is, and so that's why they keep going back to what you pointed out, which is this false left-right paradigm, which they tell everyone that's all there is. There's left or right or somewhere in the middle and there's nothing else, but that's a very narrow range of political spectrum. That's basically statism right there, and you can have left or right in statism, but there's a whole other spectrum of just not having governments whatsoever that could really free a lot of people. It's really growing, actually, like when we first started Anarchast, Anarchapulco, Anarchapulco started five years ago. It was 150 people. We're now expecting about 3,000 people. It's doubled every year. Stefan: Wow. Jeff: My show, Anarchast, a lot of people said no one had ever watched the show, but anarchy, that's crazy. They think anarchy is throwing bombs and all this sort of stuff, but it's catching on. People are catching on to a lot of this stuff now, so we're going to see what happens. We're at an amazing time in human history, because all these things are coming to a head all at the same time. All these governments are bankrupt. The central banks are about to go into hyperinflation. Then we have people waking up and starting to realize what's going on, and then you still have all these people in the universities who think that communism's the way out, so they'll probably try to push for that. Jeff: It's just amazing, incredible time, and there's going to be so much change in the next 10 years. I don't think anyone will believe what happens over the next 10 years. I couldn't even imagine what will happen, but I know it's going to be mind-blowing what happens. It's going to be that much change. Stefan: Yeah. It's unbelievable. Now, Jeff, I got to wrap up the show, but I want to ask you a couple questions I ask every guest, because I think they're cool. If you can go back in time to, let's say, 15-year-old Jeff and give yourself a piece of advice, what's a piece of advice you'd give yourself? Jeff: Oh, man. That's a good question. I would say work on yourself. I really just started working on myself over the last couple of years. I'm like 48 years old now, and it's changed my life dramatically. I didn't deal with a lot of my past issues, childhood issues, a lot of the programming that we get from our cult, our culture they call it, but our cult, through our younger years. That still stays in your head. I think if I would have, if I could go back, I'd say, "Buy Bitcoin as soon as you hear about it," and I'd- Stefan: [inaudible 00:52:55]. Jeff: ... say, "Work on yourself," like- Stefan: [inaudible 00:52:57] man. Jeff: I'd probably also say, "Don't go to the bars that much. Don't be having a lot of drunken sex. It's a total waste of time. Try to find a good girlfriend. Try to fix yourself and work on yourself more than anything." That's what I'd tell him. Stefan: Wow. Great answer. Top three books that changed your life. Jeff: A good question again. We talked about G. Edward Griffin earlier. The Creature from Jekyll Island was one of the first books that got me looking into all this stuff that I talk about today. That was a really important to my life. I'd say The Lord of the Rings is, I read it when I was very young. I used to love to read. I was probably like 12 or something. This giant book, it's even bigger than your book there. What I didn't realize about The Lord of the Rings that is interesting, I love the book, and I loved everything about it, and it wasn't until a couple years ago I realized that that ring of power was actually a metaphor for government power. I actually looked- Stefan: Wow. Jeff: ... into it a couple years ago, and J. R. R. Tolkien, who wrote the book, called himself an anarchist, so that entire book was an allegory about the problems caused by government. Those two books are pretty good. I guess the third book that I thought was really interesting, and it's like a pamphlet. You can read it in about two hours. It's called The Market for Liberty. You can actually find it online for free in PDF format, and it shows what the world could be like without government. When I read that book, it just blew my mind, because I'm sure if you even read it, you'd go, you'd be like me, you'd be like, "Wow, I never thought things could work that way or that ... " Jeff: They actually thought about how things would work without government, so there'd be like private security companies. Well, how would that work? Well, there'd be insurance as well, so the insurance companies ... For example, like people go, "Well, how would you put out fires without the government?" Which is kind of funny, because the government rarely puts out fires [inaudible 00:54:34]. Stefan: Fire insurance. Jeff: Yeah. Fire insurance, and then the insurance companies have all this insurance money, and they'll have to pay out a ton if there's a giant fire, so they actually put out fire stuff, and fire stations, and all that kind of stuff so it can all work in the free market. I think that book really, in just such a small amount of time, can really just show how the free market can handle everything. Stefan: Yeah. Well, that's great. I always, people say, "Well, who's going to pay for the roads?" Well, you just tax cars and gasoline. If you got a car and gas- Jeff: Not even tax, right, but like the businesses would own the roads. You would never put up ... Let's say you're Walmart, and you want to put up a Walmart somewhere and there's no road there. You're going to build the road, because you want people to get to your thing. Plus, not to mention there's already all roads. All roads that already exist. I don't know why people think they'll just disappear, but obviously like gas stations would have a giant interest to making sure there was roads, so they would probably do something. The gas stations would all work together and say, "Okay, let's take 10% of all of our money that we make every month and put it into maintaining the roads." Right? It's fairly basic sort of stuff. Stefan: Right. All right. Second last question today, Jeff. What's the one thing that young people need to succeed these days? Let's talk to the snowflakes. Let's talk to the millennials, the guy with the MacBook Pro at Starbucks. What's something you want to say to h

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!  

Wait... What??  That’s correct. 1972 Olympian, Jeff Galloway, who was self-coached and absorbed as much as he could from other runners has proven that to go fast, you should go slow. Hundreds of thousands of runners have trained with his method and the results he shares in this episode are nothing short of amazing. Since starting his retail store, Phidippides, in Atlanta, Georgia in 1975, Jeff has listened to runners who were looking for better and better training strategies. He has developed training methods, retreats at multiple locations around the globe, written several books, trained runners directly and remotely, written for Runner's World, partnered with Disney… well, you get the idea. We are so very lucky to have Jeff join us to tell us about his personal experiences with running and how his unique training philosophy has helped runners at all levels achieve great results while avoiding injury. This is likely to be one of those episodes that you listen to over and over because there is just so much good information. Be sure to check out the links below for even more tools and resources! Here are some of the topics we’ll discuss today: Jeff’s personal experiences running in college and his Olympic trials. Jeff counterintuitive training methods including full distance training and Run Walk Run. The benefits of group training. How The Magic Mile accurately predicts a runner’s future race times. How to leverage our human brain to keep our ‘Monkey Brain’ under control. Questions Jeff is asked: 2:50 What are some of your favorite moments as a runner? 11:55 Do you think professional / elite runners today would give up a spot in a race to help a teammate advance? 13:30 How was it having a group working together in the early 1970’s? 15:06 What’s your theory on why there aren't more big groups of people who want to train together? 17:12 Should recreational runners train in groups? 19:26 How can people get involved in your training groups? 22:20 You have runners do a 26 - 29 mile run 3 weeks before their marathon at a slower pace for 6-7 hours? 24:38 So the only you’re adding on race day is running faster? 24:55 What exactly is the Magic Mile? 26:29 How do runners get their individual Magic Mile times? 26:59 Is it just running that mile as fast as you can? 27:51 What is the Run Walk Run method? 31:14 What would you like to say to runners who have a social stigma against walking? 33:51 Does the amount of walking differ for each person? 35:24 What is the ‘Monkey Brain’? 38:13 How long should the walk-breaks be? 40:00 How does it feel to have a training method named after you? 42:29 How does it feel to have a whole event series named after you? 45:07 What is involved in your retreats? 48:02 Do you have a favorite race you recommend all runners do at least once? 53:54 The Final Kick Round Quotes by Jeff: Even on the days when I was physically destroyed, which was most of the days during the first month, I felt better in my head and in my spirit than I had ever felt in my life. I helped my father get into running when he was 52. I never heard any of my Florida Track Club teammates brag unless they were being funny about something. There is no doubt that when you have a stable of good runners you can get some really good workouts if the coach is monitoring the effort level and making sure the athletes aren’t running over their heads in workouts. The reason our Group Retreats have expanded is because there is so much interest in getting individual help with running and learning hands-on: ‘How do you do these drills’, ‘What is my form like’, ‘Am I doing something wrong?’. We found that people tend to hit the wall within about a mile of the that they ran on long runs within the last 3 weeks. And so, by going the (full race) distance, not only do people feel strong and have more belief that they CAN do it, but they actually run FASTER. (The Run Walk Run) is a method that conserves resources that reduces injuries down to practically NOTHING and allows runners to run faster in long distances. You are the captain of your ship. You are the one who determines how you’re going to run.