Podcast appearances and mentions of jeff let

In this episode, we discuss strategic steps for Equipment Leasing and Finance companies as they grow and evolve. The leadership of some of these businesses may decide to remain a certain size and complexity and be “ lifestyle businesses”, providing healthy cash flow to the owner(s) while they continue to run the business. However, other options exist, and exiting the business for a favorable multiple to a bank or other buyer can be an excellent strategy, the dream plan for many entrepreneurs.  In this interview, we interview Bob Rinaldi and discuss the potential to grow and leverage a business to realize a win-win exit strategy.  This episode is a great follow-up to our previous show, Start Early & Exit Right, as we dive deep into many of the concepts of M&A rationale. What's unique about this episode is that it is geared toward a specific target audience, our friends in the Equipment Leasing and Finance (ELF) industry. In this episode we cover: How partners such as Rinaldi Advisory Services (RAS) and Colonnade work with Equipment Leasing & Finance (ELF) companies to prepare for a successful sale (1:00) What are the biggest challenges for the independents as they look to be “bank ready” for an acquisition? (4:00)  What are some of the biggest challenges for banks pursuing an acquisition of an equipment leasing company? (9:30) What determines the level of a premium in the sale price that an ELF company can expect? (20:00) What has M&A activity looked like in recent years and what are the prospects? (23:00) What about Private Equity buyers in this space? (26:30) How partners such as Rinaldi Advisory Services (RAS) and Colonnade work with Equipment Leasing & Finance (ELF) companies to prepare for a successful sale (1:00) Bob: My practice has evolved around three target audiences in the equipment leasing space. About 60% of my clients are independent leasing (ELF) companies that I work with through the Confidential CEO Resource℠ model. This is multi-year exit strategy planning. Whether the company exits or not is not important. The idea is to get them from point A to point B so they're prepared if that time comes. The second part of my practice is working with banks, predominantly community banks who are looking to get into the ELF space. Third, I work with a handful of service providers in the industry, as well. Rinaldi Advisory Services (RAS) offers the Confidential CEO Resource℠ (CCR) as a robust, full-scope advisory service that provides clients with a broad base of support for long-term strategic management. RAS works with CEOs and Principals to provide meaningful analysis and actionable insights. The aim is to help ELF senior management arrive at strategic and tactical decisions geared toward managing growth as well as operational and financial efficiencies. Colonnade has deep experience in the ELF industry. Colonnade is a leading investment banking firm that has completed over $9 billion in M&A transactions for clients in the business and financial services industries. Colonnade has advised many companies in the EFL sector on strategic transactions. Please see our Quarterly Updates on the ELF industry here. What are the biggest challenges for the independents as they look to be “bank ready” for an acquisition? (4:00) Bob: The biggest challenge is predominantly that these founders/owners are very much entrepreneurs. They started the business. They're very much involved in the everyday transactional nature of their business. They don't have the time to gain the perspective to look at their company objectively and determine what needs to happen to be a better company from a non-transactional standpoint or to be a better company for the purpose of acquisition. Jeff:  Let's drill down a little bit on some of the biggest challenges for the independents. There's size and scale, where are you today and where are you going? Banks are the natural resting home for specialty finance companies, and ELF companies are such a great asset class for banks in particular. Obviously, they're a number of large independents, but from the bank's perspective, what are the other things you see where companies need to focus? Is it finance and accounting? Is it operations? Is it servicing? Bob: Yes. Yes. And yes. It's really all those things. But even before you get to that, let's look at the business and find components within the business that definitely will never, ever fit in a bank. I'm able to identify those things. You then have to decide what to do with those things. Do I jettison those things completely? Do I sell those off? Do I break it outside of the company and put it in a separate entity so that what is left is sellable and simple to understand? Compare that to a buyer looking at the company and thinking, “I like this, I like this. I hate that. Therefore, I'm not doing it [the acquisition].” For example, say that there is a heavy services component of the (ELF) business; services component being something that has morphed, be it operational leases or servicing equipment that is leased. A bank can't be in that business. If that is an absolute key critical component to your leasing business, then a bank buyer is probably never going to be the buyer, which is going to leave you looking at non-financial institutional-type buyers, and they're fairly limited, so that's a problem. That is when you look at it and go: “If that's what we're always going to do, then this maybe is just going to be a lifestyle business. Let's just find ways to improve the income generation, the profitability, and keep it as a lifestyle business.” What are some of the biggest challenges for banks pursuing an acquisition of an equipment leasing company? (9:30) 1) The banks must use experienced advisors who understand the appropriate valuation models. Bob: If the bank has not been in the business before and their only experience with acquisitions has predominantly been buying other smaller banks, the first challenge is the valuation models. Banks are used to paying a multiple of book value. Leasing companies are not valued that way; their valuation is based on a multiple of earnings or pretax adjusted net income. In a typical leasing company, most of the leases are on a fixed term, fully amortizing type of a structure; therefore they just generate income. But the assets don't stay on the balance sheet that long, they continually roll-off at a rapid rate, so you've got to keep putting on more. It's really not an asset play as much as it is a net income play. Jeff: When we talk to banks as acquirers of these businesses, from either the buy-side or the sell-side, you're absolutely right. It's all about the income-generating opportunity. Yes, there are assets associated with it, but much more importantly, it's “What's the potential earning stream for this business within the bank?” (See: Discover the Rationale for a Synergistic Business Merger). Bob: That really comes down to the financial institution's advisor, a buy-side advisor. If they've not had much experience in the equipment leasing space, especially current experience like Colonnade has, they're already at a very big disadvantage because now you've got two entities that are blind and stating the same thing and focused on book value, so they're getting bad advice along with their own preconceived ideas. That's like a double whammy right out the gate. It's common when you find that a bank or their board, for whatever reason, have just got very comfortable with a buy-side advisor, who has never had that much experience at it but they've just gotten very comfortable with them and they wouldn't even conceive of going outside. A lot of this gets really back down to, “Is the bank nimble? Is the bank flexible? Does the bank have a CEO that has cut a bigger vision?” The same thing with the board, the death of any kind of an institution is just getting so stuck in your way that you just can't get out of it. 2) The CEO of the bank must have a visionary leadership style that allows the acquired company to thrive. Bob: It all still goes back to the CEO of the bank and how progressive they are, how aggressive they are. And aggressive does not mean they're careless. Jeff: The folks that we generally work with on the banking side have made that decision. They said, “Okay, we're going to get into specialty finance. We want to do it in X, Y or Z asset class, and we have the headset to bid accordingly, and that these businesses are valued differently than bank deals. The multiples are different, the metrics are different. We're committed, we've got board approval, we've got senior leadership approval and we're going to go ahead with it.” Bob: You and I know one of the smartest, most aggressive community bankers: Chuck Sulerzyski ​of Peoples Bank of Marietta, Ohio. Peoples Bank is located in the Southeast corner of Ohio, squarely in Appalachia country. How does a bank that size, originally ~$1 billion in assets when he took it over and roughly $7 billion today, make such successful leasing company acquisitions? One located in Vermont and one located in Minnesota? If you take a look at the numbers, the ROA and ROE of the bank have improved dramatically. Their yields and spreads have increased dramatically. Their asset growth has increased significantly in the commercial real estate (CRE) and in the commercial and industrial (C&I) sectors. His shareholders are being rewarded handsomely and will continue to be. Jeff: Chuck sets a great example. He has been aggressive in good ways. Peoples Bank also acquired an insurance premium finance company, and they're diversifying.  Chuck has the right headset in that he looks to acquire businesses to expand and diversify their geographical footprint. That's a real success story, in my view.  Bob: If you're going to acquire a leasing company that's growing, that's used to growing assets, the last thing you want to do is turn them into a bank. That's the whole premise for why you're going to buy a leasing company – is to expand the scope of the bank, not to contract it. It requires an introspective look of the CEO and his team: can they make an acquisition and not micromanage it and end up turning it into a bank? 3) Banks must be able to create objectives around diversification of geography and asset classes.  Bob: Equipment leasing is not a geographic-specific industry unlike, let's call it, commercial real estate. Banks are very familiar with commercial real estate. Real estate is always local. Commercial real estate is local, you've got to know the geography that you're in very well so that you understand the commercial real estate in that market. Banks must understand what they're trying to achieve in three to five years in terms of what percentage of their (Commercial and Insurance) C&I assets they want in various sectors.  How much do they want to get to in ELF? What do they want it to look like in three years, four years? Depending upon how big that number is, that determines the modality of the type of equipment leasing business you could get into. There are multiple facets to the equipment leasing industry: 1) small ticket, (transactions less than $250,000), middle-market/mid ticket (up to $5 million per transaction size), and large ticket (above $5 million per transaction). Jeff. Take Wintrust. They're not really “a bank”. More than 40% of their loan portfolio is insurance premium finance. They've got a big equipment finance business on top of that. There's probably 50% to 60% of loans that are non-traditional banking assets. As a result, the ROA on that bank is considerably higher than its peers; and as a result, the stock trades higher.  And Peoples, as we've discussed, has the right headset that they need to acquire or look to acquire national platforms outside of Marietta, Ohio. Obviously, they've done some bank acquisitions too in footprint, but expanding to get national business is part of the CEO's strategy.  What determines the level of a premium in the sale price that an ELF company can expect? (20:00) Bob: It falls under the quality of earnings, platform, and quality of human resources. Quality of earnings: I think about the repeatability of the earnings, as opposed to having a trend line of earnings that is a sawtooth (up and down, up and down). Quality of earnings should be fluid and show continued ramped-up growth over a period of time. Platform: The ability to scale. What's their technological capability? What's the platform built off of, is it homegrown? Is it well protected? Is it SOC compliant? If you had more capital, can you scale it? Quality of human resources: What does the management team look like? What's the average age of the team? What are their qualifications? What does the core management team look like behind them? If you cover all three of those pretty darn well, you're going to get the higher end of the premium scale for sure. What has M&A activity looked like in recent years and what are the prospects? (23:00) Bob: Activity's been strong for the past few years. Part of the activity was exacerbated when everybody thought that in 2021 there was going to be a new tax act and capital gains were going to go up.  The biggest reason over the past four to five years is because you've got an aging-out (in the midst of the Great Resignation) of the Principals of these companies. It's just a normal progression, and it happens every five years or so. You get a number of individuals who have had their own leasing companies who started them 20 odd years ago. If they started 20 years ago, here we are 20 years later, they're in their mid-60s to late 60s. If they don't get out now, when are they going to exit? Because typically there's going to be an earn out. If you wait till the age of 70 to get out, you may be working on an earn out between the ages of 70 and 73. On top of that, there's the aspect of an ELF company having a capital constraint. At some point, their capital is not going to hold them to keep borrowing on their line of credit because the debt-equity ratios will get too high and they'll have a hard time borrowing. It's really at about that time when they have to start thinking about what's next. Do we bring in another equity partner? Do we bring in some sub-debt? All that does is kick the can down the road. And I always tell them at that point: “You're already selling part of the company. Just sell the whole thing.” Listen to this podcast episode/read through the shownotes to see the Four Reasons Company Owners Consider a Transaction (15:25) What about Private Equity buyers in this space? (26:30) Jeff: We regularly get calls from folks looking to find platforms to acquire and build upon. There are some opportunities there: To remain independent, nimble, and flexible outside of the bank model, and take in additional capital to grow and potentially enhance the financing capabilities through securitizations and others. Bob: The equipment leasing industry is a fairly mature industry. It's fairly sophisticated. For an independent leasing company to bring in private equity, I see that as only a solution if you don't believe you're able to sell the whole company right now. The PE firm is investing to get double-digit returns, so that means they're going to come in and put you (as the owner/operator) on a huge ramped-up treadmill. You are going to have to keep up or they're going to lose interest. And you've sold part of the company. Now, granted, you've got a smaller piece but now have a bigger pie.  Jeff: That makes sense. There are some examples of successful private-equity-backed equipment finance companies, but as we have found – the universe of financially oriented sponsors that really want to put a lot of capital into the business and are willing to wait a long time to get their return – is quite limited. Most folks attack it from the financing standpoint. It can be a good option if you have an aging founder that wants an opportunity to take some chips off the table and let the next generation continue to run it. But you're right, it is a different exercise being put on that treadmill. Bob: It's a much different exercise. On the other hand, where it does work really well, is when a PE firm is backing a very experienced individual or a team who is going to start up a new entity. They could start this new entity and scale quickly with the help of private equity. They'd have a chance to really leverage that with some serious growth. Then it makes complete sense.

Throughout this Portals adventure, we have explored in many ways how to create the inner and outer space that would allow the next phase of universal and human evolution – the future – to appear. It's time to embrace the bold proposition that evolution has moved forward, and is still doing so, and the future has arrived. Homo sapiens, welcome Homo Universalis, the whole person. The evidence of individual and collective transformation is turning up in many places around the world. Homo Universalis is not meant to be characterized by physical changes but by changed lives and communities; the liberation of remarkable new intelligence, new capabilities, the elevation of thinking and behavior, and healing at many levels. Part of the human species updating represented by Homo Universalis is that each one of us can take steps to activate the new elevation and consciousness in ourselves. This conversation takes a deeper look at some of those steps. Join Aviv Shahar and Jeff Vander Clute for Homo Universalis Activates. KEY TAKEAWAYS 02:51 – Aviv welcomes back to the show, Jeff Vander Clute, to engage in a rich discussion on today's topic: Homo Universalis Activates14:46 – Aviv reflects on creating ecologies where people discover knowledge and release their inner intelligence and brilliance for themselves22:10 – The building of resilience, endurance, and mental toughness for growth opportunities29:03 – Explaining the concept of Homo Universalis and Shadow Work37:59 – The cleansing, sublimation, self-absolvement and forgiveness work41:32 – The continual updating of our own personal sense-making maps46:35 – Self-authoring, alignment & inquiry-based perception seeking55:27 – Why pursue shadow work?1:01:27 – Aviv provides some personal examples of how he's practiced shadow work in the past1:09:32 – Healing power1:14:31 – Closing thoughts and insights from Aviv and Jeff TWEETABLE QUOTES “There is always a consideration in me of how do you no longer do teaching in the old way of teaching, which is the transference of knowledge, but really create an ecology and an experience where individuals and groups can come into the ecology and that experience such that the knowledge, the discovery, the insight is self-arising.” (14:50) (Aviv)“I never completely resolve the pattern if it's in the world, but it's not present anymore personally; it's present transpersonal. And so now, because I've done the work, life says, ‘Fantastic, here's somebody who knows what to do so let's give him now a dump truck full from the USA's energy field' as an example. So, I get to do it again for the collective but with tools and with resources. And so my sense is that this could be world work. And we could each potentially do world work.” (20:29) (Jeff)“So, there's a great wisdom in life when immaturity is actually an asset for rapid growth. And then with wisdom I've become more discerning.” (25:47) (Jeff)“Let's just be aware and let's name the other fields such that the great fascination with shadow work does not become an end to itself but is rather recognized and appreciated and embraced inside a bigger context, which is this idea of human development in the evolutionary context from the homo sapiens or the sapien sapiens into the homo universalis.” (34:59) (Aviv)“Regarding alignment practices, as I experience alignment it is about aligning with life - the flow of life, the direction and movement of life. And that's a capacity that can be built over time - the capacity to sense in subtle ways how life is moving and then flow with life. And what I have found is life will then show me where there is shadow work, where there are opportunities to cleanse, or forgive, or release blockages, or improve my energy management. I'll be the first one to say right now that I'm a work in progress.” (52:07) (Jeff)“What you're offering, through these investigations, is a clear understanding of some of the ways that we can participate. And as we participate consciously in the flow of life and the unfolding of these empowered, nonlinear solutions, they have more power because they have our power.” (1:17:58) (Jeff) RESOURCES MENTIONED Portals of Perception WebsiteAviv's LinkedIn Aviv's TwitterAviv's WebsiteJeff's LinkedIn

The latest In Touch With iOS with Dave he is joined by Jeff Gamet and guest Chuck Joiner. Jeff has troubles with sidecar on MacOS using his iPad. We discuss this and Universal Control. An Apple patent was discovered for a new hinged keyboard for iPad that might show the iPad running MacOS. Apple delists old Apps in the App Store not updated in 3 years. Plus tips including how to stream a screen recording to apps like TikTok, Discord, and others. Plus many more tips for your iPhone and iPad.  The show notes are at InTouchwithiOS.com 
Direct Link to Audio Links to our Show Click this link Buy me a Coffee to support the show we would really appreciate it. intouchwithios.com/coffee  We have a brand new way to support the show become a Patreon member patreon.com/intouchwithios Website: In Touch With iOS YouTube Page In Touch with iOS Magazine on Flipboard News Apple Shares Star Wars Day 'Behind the Mac' Film Update: AirTag firmware update enhances unwanted tracking alert AT&T Raising Prices on Legacy Plans to Encourage Customers to Upgrade to New Plans Camo app now lets you use iPhone as your Mac webcam with FaceTime, Safari, and QuickTime Apple sends iPad Air 2 and iPad mini 2 to vintage products list Apple Watch Series 7 now available from Apple Refurbished Store Apple Lowers Trade-In Values for Macs, iPads, and Apple Watches Topics Beta this week iOS15.5 Beta 4 has been released.  Apple Seeds Fourth Betas of iOS 15.5 and iPadOS 15.5 to Developers Apple Seeds Fourth Beta of watchOS 8.6 to Developers Apple Seeds Fourth Beta of tvOS 15.5 to Developers Apple filed a patent Could MacOS run on an iPad? We had quite the debate.   Apple wins a Patent for a next-gen hinged keyboard iPad accessory with multiple modes that could possibly double as a Hybrid Device Apple Bringing macOS To iPads Is the App Store overloaded with outdated apps?  Apple has begun delisting apps that have not been updated in over 2 years. Is that fair to developers who keep apps going that long? Apple shares criteria for removing 'abandoned' software from App Store, extending response window Apple will delist App Store apps that haven't been updated recently Jeff was having issues with sidecar on MacOS and his iPad. It's really unstable. We discuss its use and what Apple can do better. Maybe universal control will replace it?  How to find the hidden Apple Music sleep timer on iPhone and iPad Stream Recordings happen by using the button in Control Center, you can then pick an app into which your recording will be saved, to Photos, or direct broadcast to other apps you may have installed like Twitch, Discord, and TikTok.    More tips we review.  Share your Wifi Password  End a call with Airplane mode Flashlight brightness button Setting Lossless mode a better quality audio by going to Settings>Music>Audio Quality and then turn on the ‘Lossless Audio' option. You will then be able to select this for your Wi-Fi Streaming and Downloads. Tap and hold buttons for menus Jeff shares some Flashlight tips.  Our Host Dave Ginsburg is an IT professional supporting Mac, iOS and Windows users and his wealth of knowledge of iPhone, iPad, Apple Watch, and Apple TV. Visit the YouTube channel https://youtube.com/daveg65 follow him on Twitter @daveg65.and the show @intouchwithios Regular Contributor Jeff Gamet is a podcaster, technology blogger, artist, and author. Previously, he was The Mac Observer's managing editor, and Smile's TextExpander Evangelist. You can find him on Twitter and Instagram as @jgamet and YouTube https://youtube.com/jgamet/ Also catch him on nis podcast with Bryan Chaffin The Context Machine. About our Guest Chuck Joiner is the host of MacVoices and hosts video podcasts with influential members of the Apple community. Make sure to visit macvoices.com and subscribe to his podcast. You can follow him on Twitter @chuckjoiner and join his MacVoices Facebook group.  

On this episode of My World with Jeff Jarrett, listen as Jeff and Conrad discuss Part 1 of Jeff Jarrett's first run in WCW as a member of The Four Horsemen! Topics include Jeff's departure from the WWF, signing a 1-year deal with WCW, Flair's injury, Gorilla Monsoon's heat with Jerry Jarrett, becoming a Horsemen, Sting's attack, defeating Mongo, and much more! GEICO - Do you own or rent your home? Sure you do! And it's hard work. But you know what's easy? Bundling with GEICO. Go to GEICO.com, get a quote, and see how much YOU could save. It's GEICO-easy!  CREDIT KARMA - Whether you're refinancing credit card debt or paying for an upcoming expense, Credit Karma uses your credit data to show you fresh personal loan offers that are personalized to you. Ready to apply? Head to Credit Karma.com/LoanOffers to see personalized offers with your Approval Odds right now. KICKSTARTER - Tales from the Road Volume 2 is live on Kickstarter from Headlocked Comics featuring comic book stories co-created by the biggest names in wrestling. Plus, gorgeous painted cover by WWE Hall of Famer, Jerry “The King” Lawler. Go to Kickstarter.com to get your copy of Tales From The Road Volume 2!  VEGASWINNERS.COM - Just be among the first 1,000 right now at VegasWinners.com for your $1,000 of FREE pointspread picks. VegasWINNERS is completely private, no one to EVER speak to. Be one of the first 1,000 to log on right now…and get your $1000 of FREE pointspread picks and apply them to my world-famous football Game of the Year.  LEGACY - If you've experienced a loss of motivation, energy or sex drive, or if you're noticing that you're a little softer around the middle than you used to be, it could be that your testosterone levels have dropped. Don't settle for average, man up at LegacySupps.com and use code WHW for an additional 10% off your entire order.  ECHELON - Echelon is the affordable way to get the workout equipment, theworkout community and an instructor's motivation right at the comfort of your own home. Get an Echelon E-X-3 bike risk FREE for 30-days PLUS FREE shipping and assembly.To get this exclusive radio offer with these free bonuses valued at two hundred and fifty dollars, go to EchelonFit.com/JEFF Let us help you save some money and get out of debt today over at www.SaveWithConrad.com You can enjoy this episode and other clips of MyWorld everyday on YouTube! Subscribe and turn on your notifications at www.MyWorldOnYouTube.com Did you know you could be enjoying My World with Jeff Jarrett, even a week in advance on ADFreeShows.com? ADFreeShows.com is a SUPER Patreon page that brings all Conrad's podcasts under one roof, early and AD FREE! Not only do subscribers get the regular shows, they also have access to BONUS content you won't see or hear anywhere else! Join ADFreeShows.com for as low as $9 a month or choose a higher tier for more access to your favorite podcasts! If you want the world to hear about the exciting things your doing in your business then you need to advertise on My World! We can help make a difference in your company today over at www.AdvertiseWithConrad.com We are always coming up with great My World gimmicks over at BoxOfGimmicks.com. Check it out now and grab your My World gear today! Learn more about your ad choices. Visit megaphone.fm/adchoices

What You'll Learn From This Episode: How to build a cash cow and build the value of your business Finding ‘the right guide' to help you with your business Knowing the simplest way to run a business Related Links and Resources: Our free giveaway will be our new book "Make More Money: The Business Owners 5-Step Plan for Bringing in More Cash". If you want get a free copy of it, go to the www.TheCFOproject.com/MoneyBook Summary: Jeff Prager, co-founder of The CFO Project. His company has one purpose: to help you make more money. He has been a former CEO/CFO and owner of several successful multimillion-dollar companies. Jeff's breadth of experience is remarkable and extremely valuable to entrepreneurs. He's been a CPA for over 40 years, so he understands all the confusing numbers stuff. But he's also an author, speaker, and life-long entrepreneur, not just some paper pusher. Because of his vast experience as both a CPA and a business owner, he has a firm grasp on the challenge's businesses face whether they're start-ups or seasoned pros. He's great at simplifying the numbers and an expert at providing a clear road map to improved profitability and cash flow. Here are the highlights of this episode: 1:52 Jeff's ideal Client: We normally work with small to medium size businesses that want to generate more cash flow, boost cash reserves, fund their growth, potentially build a cash cow and build the value of their business. 2:22Problem Jeff helps solve: We help companies make more money - PERIOD. That's our whole mission. 2:50Typical symptoms that clients do before reaching out to Jeff: Let me target a few for you. If you're stressed out every month due to inconsistent or lack of enough cash flow, if you're frustrated by financial statements that seem to be written in foreign language.. and by the way they are. Even though I'm a CPA, when I own my own businesses, I realized they weren't telling me the right story. The data that was provided was not helping me run my businesses more effectively. If you're angry that you started your business to make money and gain freedom, neither of which are happening at your desired level. If you're worried that you are in a 'catch 22', you don't have enough cash to expand your business but you can't grow without more cash. And the final one is if you struggle to set targets for your organization and you feel that you're navigating a motherless ship, then you're ready for us. 4:11 What are some of the common mistakes that folks make before finding Jeff and his solution: You hit the nail on the head. The first one I always talk about is not having a guide who's been there, done that. There are lots of coaches and consultants out there who have never ever run their own business. The second thing is focusing on sales' topline growth or net profit bottom line growth, but not focusing on cash, that's a huge mistake I see out there. Number three, not using that information to create 30-day action steps. And the fourth one I find is they solve problem on a tactical basis, in other words they look for 'A solution' like SEO, or direct mails. But they don't look at how it factors into the whole business funnel from lead generation to cash in the bank. Therefore, making decisions not based on the long term. 5:28 Jeff's Valuable Free Action (VFA): Start looking on where you want to end up versus where you are today. Think like an owner of a business not like an accountant. Review your cash coming in and going out each and every week. And then to project out the next couple of weeks, months, and years. So, you're trying to start with the end in mind, work backgrounds to how much cash do you have today, how much will you have tomorrow, how much you will have next month, and next year. That's how I look at it. 6:20 Jeff's Valuable Free Resource (VFR): Our free giveaway will be our new book "Make More Money: The Business Owners 5-Step Plan for Bringing in More Cash".

What You’ll Learn From This Episode: How to build a cash cow and build the value of your business Finding ‘the right guide’ to help you with your business Knowing the simplest way to run a business Related Links and Resources: Our free giveaway will be our new book "Make More Money: The Business Owners 5-Step Plan for Bringing in More Cash". If you want get a free copy of it, go to the www.TheCFOproject.com/MoneyBook Summary: Jeff Prager, co-founder of The CFO Project. His company has one purpose: to help you make more money. He has been a former CEO/CFO and owner of several successful multimillion-dollar companies. Jeff’s breadth of experience is remarkable and extremely valuable to entrepreneurs. He’s been a CPA for over 40 years, so he understands all the confusing numbers stuff. But he’s also an author, speaker, and life-long entrepreneur, not just some paper pusher. Because of his vast experience as both a CPA and a business owner, he has a firm grasp on the challenge’s businesses face whether they’re start-ups or seasoned pros. He's great at simplifying the numbers and an expert at providing a clear road map to improved profitability and cash flow. Here are the highlights of this episode: 1:52 Jeff’s ideal Client: We normally work with small to medium size businesses that want to generate more cash flow, boost cash reserves, fund their growth, potentially build a cash cow and build the value of their business. 2:22Problem Jeff helps solve: We help companies make more money - PERIOD. That's our whole mission. 2:50Typical symptoms that clients do before reaching out to Jeff: Let me target a few for you. If you're stressed out every month due to inconsistent or lack of enough cash flow, if you're frustrated by financial statements that seem to be written in foreign language.. and by the way they are. Even though I'm a CPA, when I own my own businesses, I realized they weren't telling me the right story. The data that was provided was not helping me run my businesses more effectively. If you're angry that you started your business to make money and gain freedom, neither of which are happening at your desired level. If you're worried that you are in a 'catch 22', you don't have enough cash to expand your business but you can't grow without more cash. And the final one is if you struggle to set targets for your organization and you feel that you're navigating a motherless ship, then you're ready for us. 4:11 What are some of the common mistakes that folks make before finding Jeff and his solution: You hit the nail on the head. The first one I always talk about is not having a guide who's been there, done that. There are lots of coaches and consultants out there who have never ever run their own business. The second thing is focusing on sales' topline growth or net profit bottom line growth, but not focusing on cash, that's a huge mistake I see out there. Number three, not using that information to create 30-day action steps. And the fourth one I find is they solve problem on a tactical basis, in other words they look for 'A solution' like SEO, or direct mails. But they don't look at how it factors into the whole business funnel from lead generation to cash in the bank. Therefore, making decisions not based on the long term. 5:28 Jeff’s Valuable Free Action (VFA): Start looking on where you want to end up versus where you are today. Think like an owner of a business not like an accountant. Review your cash coming in and going out each and every week. And then to project out the next couple of weeks, months, and years. So, you're trying to start with the end in mind, work backgrounds to how much cash do you have today, how much will you have tomorrow, how much you will have next month, and next year. That's how I look at it. 6:20 Jeff’s Valuable Free Resource (VFR): Our free giveaway will be our new book "Make More Money: The Business Owners 5-Step Plan for Bringing in More Cash".

Jeff & Will talk about their past week of business decisions and the coming week they’ll spend at the Podcast Movement conference. They also remind the authors in the audience to check out the new Big Gay Author Podcast. The guys talk about the production of The Wiz they just saw as well as the current season of Pose. Together they review Lucy Lennox’s Wilde Love and Jeff reviews Dreadnought by April Daniels. Amber Smith joins Jeff to talk about her young adult novel Something Like Gravity. Amber reveals how the characters of Chris and Maia had been the main characters in different books before she decided they’d be great together in a single book. Amber also discusses how she got started writing, the trademarks of her books and the research she does to create her characters. Complete shownotes for episode 201 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript – Amber Smith 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 Amber to the podcast. It is great to have you here. Amber: Thank you so much for having me. I’ve been really looking forward to this. Jeff: So I reviewed ‘Something Like Gravity’ back in episode 195 and it was the summer book that I didn’t know I was looking for. I’d like you to start us off by telling everybody, in your own words, what this book is about. Amber Well, this book is about a lot of things, but really, at its center, it’s a story about falling in love for the first time and finding yourself in the process. It’s told between our two main characters, Chris and Maia, and both of them are going through a really difficult time in each of their lives. Chris has recently come out as transgender and he’s really trying to figure out how to navigate his life now that everything’s suddenly changing, and he’s also trying to process this really terrifying assault that he survived the year earlier. Maia is dealing with the recent death of her older sister. And so both of their lives look very different, but the one thing that they have in common that brings them together is that they’re both trying to figure out who they are going to become in the face of these life changing events that they’ve been through. Jeff: What was your inspiration behind the book? Amber: There are various threads of inspiration, but it’s funny, I actually started writing this book as two separate books. Chris was the protagonist of one and Maia was the protagonist of the other. And I do generally work on two things at the same time because, if I get stuck on one I can sort of hop over to the other thing I’m working on. I always thought of these as separate books in the beginning and Chris’s story was primarily about coming out, and being queer, and being trans, and trying to figure all of that out. And Maia’s was a story about grief. At a certain point, I think it became too hard for me to continue working on these stories because both of them were super personal. I was drawing from a lot of my own experiences with coming out as a lesbian and also, you know, dealing with the loss of loved ones myself. At a certain point, I thought, you know what can I do to kind of make this easier on myself? And I thought about giving Chris a love interest. And when I started to think about what would be the kind of person that would be really good for Chris, and would kind of balance him out, and all of those wonderful things that happen in a relationship. I immediately thought of Maia – this other character that I was writing, and that’s when I realized, oh my gosh, I think these stories were always meant to be one story. And it just took me a while to realize it. Jeff That’s amazing to me on a couple of levels. I can’t do two projects at once because it makes my head want to explode. But also there’s – just coming back to the title, ‘Something Like Gravity’ is like gravity just pulled between these two stories and brought these two together from the disparate places that you had them. Did the characters fundamentally change when you brought them together or did everything just click into place once that happened? Amber: Well, not necessarily so. I think the biggest part was that I had been working on these stories for so long. I don’t think much of my original writing made it into the final book. I think doing that writing on both of the stories prior to lining them as one, really helped me to get to know each character in that sense because, I knew each of them so well, I knew their voices, I knew their histories. It was sort of easy to bring them together, but I had to rewrite everything better. I think it was almost like telling the stories of two people I knew really well already. Jeff: Any chance that those original stories get to become prequels or something? Amber: Oh my gosh I love that idea. Something to think about. Jeff: As you noted, I see both Chris and Maia have these weighty things that they’re dealing with on both sides. What was your process to present that authentically to the readers? Amber: I always, whenever I’m starting a story, I begin with my own experience and I always sort of view writing as therapy in a way. So like Chris and Maia’s experiences start out as something very real that’s happened in my life. But then as I write them they become something else. So, I don’t know. I think I just always have in the back of my mind the roots – like emotion, or the emotional world that I lived in as kind of the parameters for this story. And so hopefully that helps to keep things feeling real and authentic. Jeff: And then you put the love story in with this. The way that you counterbalance what they’re going through with this super sweet love story. It was unique to me how that worked because for some of the story at least, they’re almost not dealing with their issues because they’re finding this in each other. How did that kind of all mix together for you? Amber: I think one of the things I’ve realized as I was writing the book, separately in the beginning, was that I was focused so much on the pain that each of these characters felt. I’ve written about trauma, and assault, and grief, in the past and it felt like I was sort of rehashing – or reopening old wounds of my own. I just thought I really need to do something different here. And it took me a while to figure out that I wanted this to be a love story because, as you know, it took me a while to kind of wrap my head around why was I writing it that way in the first place? I had this switch flipped in my mind when I started to think about the love story aspect of, you know, what I’d love to do with this book is make love be more powerful than the pain that each of them were experiencing. And so that kind of helped me to steer this story in a different direction. And then when I really started thinking about it, that love, and connection, and relationships, those are the things that really helped me heal during the hardest times in my life. And so I think it can be so easy to focus on the darkness sometimes but, when I really thought about even my own life, I realized the things that really got me out of those dark places were my connections with other people, and learning how to love myself, and falling in love for the first time. And so that became something I want to do – explore more than that other side of things. Jeff: And it’s interesting too that essentially the secondary story for both characters is their relationship with their parents. For Chris it’s his parents coming to understand that Chris has come out as trans, and for Maia they’re going through the same grief that she is, having lost their daughter. How did you approach layering that in? Because, again, you’ve balanced this out so beautifully, how it just all kind of ebbs and flows together – but there’s a lot in play here. Amber: Oh thank you. You know, I think the family dynamics with each of the characters – I will say that’s the one thing that kind of carried over when I was working on these as separate books. In my original ideas for both Chris and Maia, one of the big things that they were dealing with were these really complicated family issues that were going on. Yeah. So I think I just I always knew from the beginning I wanted part of their journeys to be trying to work out all of this messy, complicated, emotional stuff with their families and with themselves. I don’t really know how I layered it in because I think it was just always in the back of my mind that that stuff needed to be there. And I had thought of Chris and Maia’s relationship, the way that they grow and discover more about themselves, as kind of the framework of getting to the place where they were able to deal with their family stuff because they evolved too. Jeff: Did you have to do a lot of research? In your acknowledgments in the book you list out a whole bunch of people and things that you looked at to help craft all this, and so it seems like there was quite a bit that went on to create the characters, and create the situations, and then, as we kind of talked about it a little bit, getting it authentically on the page. Amber: For this book in particular I really reached out to a lot of different readers and friends, people who have gone through similar things to Chris and Maia. So I had friends, who identify as trans or non binary, read different sections of the book looking at Chris’s perspective. I even had a professor at one of the universities here in North Carolina really go through the entire manuscript with a fine tooth comb because, while in particularly looking at Chris’s side of the story because even though I kind of started with a kernel of my own experience, for Chris as a queer person. I’m not transgender, so I wanted to be very careful that I wasn’t doing anything in my narrative, and my representation, that would be in any way harmful or misrepresenting Chris as a transman. And so that was super super helpful. I found that the areas that I was really worried about in Chris’s story, were not the areas that were pinpointed by my readers as being problematic. I think that goes to show, it really was important for me to seek out those other perspectives, because the things that I thought might be issues were not what they thought were issues. So yeah, that was a really big process… getting that feedback from those other readers. Jeff: One of the things I’d mentioned in my review, what struck me about the book, is a sweet love story, two characters with trauma, and yet the book itself kind of felt like this lazy summer vacation. I think some of it is because of where it set. So it’s a small town, and you’ve got Chris and Maia essentially living on farms and separated by this field, and I could just envision hanging out on the porch, and just kind of letting the summer go by. Bike rides, and these adventures they went on – where they went to the to the adjacent town to check things out. And it really kind of held the story together – and kind of kept it in this very innocent place. Was that deliberate, or did it just happen that way, because of how it all pieced together as you were going? Amber: You know, that part of this story really was deliberate. Once I started trying to figure out how to weave Chris and Maia’s stories together, I really sat down and I did a lot of pragmatic planning and plotting, which is not something I usually do at all. I think I knew trying to combine two stories, I really had to know where I was going because it could get really confused. So one of the first things I decided was the setting and the timeframe. I decided I wanted it to take place in a rural North Carolina town, which Carson is fictional, but it’s based on a lot of the small towns on the outskirts of Charlotte where I live. I knew I wanted it to take place across the course of one summer and I did that partially because of that feel that you’re talking about. I really wanted to give Chris and Maia a space where it felt like their lives and their realities are somewhat suspended for a little bit of time, so that they could have the freedom to figure out what they’re going to do, figure out how to process what’s happened in their lives. And I always felt, growing up, summer is sort of this weird Time Warp kind of area, where things just don’t happen in the same way as the rest of the year. And so I definitely wanted to bring in that kind of like lazy feel because it feels like we have all the time in the world, but of course, we know summer only last so long. That’s also a little bit of a ticking clock I could put in there. Jeff: What do you hope readers take away from the book? Amber: I really wanted readers to be able to look at Chris and Maia’s story and find pieces of themselves in each of these characters. Even if a reader isn’t trans, or queer, or grieving, I hope that they might be able to find some commonality with Chris and Maia. And maybe that’s just the simple fact of being able to relate to falling in love for the first time, but that for people who do identify with the things that Chris and Maia are going through, maybe if the reader is trans, or non-binary, or going through a major loss, or some kind of upheaval in their lives, I would hope that they could look at Chris and Maia as a way of knowing that there are people in the world who understand what they’re going through and they’re not alone. Jeff: Let’s talk a little bit about Amber Smith’s origin story. What got you into writing and coming specifically into writing these powerful young adult books? Because this is not your first one that deals with weighty material. Amber: I sort of came to writing in a very roundabout way – as a lot of people do. So, when I was growing up, I always wrote. I always kept journals. And when I was a little bit older, like a teenager, I wrote poetry, but all of my writing was very personal and not something I would ever show anyone. It was more like therapy. Like, even when I was a little kid, I remember the little diaries. And it was like I would just write about what happened that day, just sort of like dumping everything out of my head. So I was actually much more involved in the visual arts all throughout my life. That’s what I really focused on when I was in high school. I ended up going to college for painting. I had my BFA in painting and then I went on to get my master’s in art history because I had worked in some art gallery settings as an undergrad and I was like, “You know, I think I want to be a part of this whole art world in this way, maybe not as an artist, but as someone who kind of brings art to people.” And so I did that for a long time. I was working in my role as a curator, and during that time I was doing a lot of writing for my work, but it was more writing about art history and biography-type writing. Even though I loved what I was doing in the art museum world, I really missed working on my own creative stuff and so it was then that I really looked at writing as, not just a therapeutic outlet, but it became more of my creative outlet, and that’s when I started working on my first book. That first book actually started out as very much therapeutic writing and then the longer I spent with this story, it kind of morphed into something more fictional, and I’ve I guess I was sort of hooked at that point. I realized, “Wow, you know, I can really do a lot with fiction.” And it was really healing, just like when you read a fictional book, it can be a lot easier to sometimes relate to a fictional character and have empathy for their situation, and kind of see the big picture more so than we can sometimes do for ourselves. And that’s sort of what writing became for me very early on. That’s how I got here. Jeff: That’s a good story. I like how you went from essentially one creative expression to another – from creating works of art to now creating a different work of art, if you will. Amber: ‘Something Like Gravity’ is the first book where I’ve been able to kind of bring in some of my art background. So that was really fun. Jeff: Yeah, with Maia’s photography, I could see how that could bridge that gap a little bit. Amber: Yeah. Jeff: What would you say is the trademark of an Amber Smith book? Amber: I would say the trademark is the story is going to be emotional. It’s going to deliver some difficult stuff and it’s going to be very real. So I definitely don’t like to kind of sugar coat things all that much, so it can be a little gritty. Jeff: Gritty is a good word for it actually, having now read this one. Who are some of your author influences? Amber: Oh, you know, some of the authors who really influenced me the most are the authors that I read when I was in high school. I remember YA wasn’t necessarily a thing yet when I was a younger teenager, but in my senior year of high school I remember there were several books that came out right at that time and I was a big nerd, so I volunteered at my school library, and my librarian was like my best friend, so she would give me all of the books that were coming in – for me to take home and read her first, before anybody else. I remember reading ‘Speak’ by Laurie Halse Anderson. And that book really stands out for me. It just changed my life because I think it was one of the first times I remember feeling like a book truly brought me this deep sense of comfort. I was seen and understood. I was not alone. And that really stayed with me. And then there were other books that came out right around that time, ‘The Perks of Being a Wallflower’. That was a huge book for me that I read when I was in high school. Let’s see. Sonya Sones, her debut, ‘Stop Pretending’ came out and it was written in verse. And that was also the first time I had read something like that and it really made an impact. I think back to those books I read when I was a teenager, and the ones that really affected me were those ones that were about really serious issues, and they are the ones that made me feel like I was not alone. There was hope things could get better. I guess that’s sort of where I’m coming from now as a writer. What were the stories I needed when I was a teenager? Jeff: And what’s coming up next for you? Amber: Well, I’m not entirely sure. I have a couple of things in the works. I’m pretty sure what is going to be next is going to be a middle grade book. So, going a little bit younger. So that’s really exciting. I’ve been wanting to kind of explore different genres. I think back, middle school was actually a lot more traumatic for me than high school. So it’s funny I haven’t gone there yet. Jeff: I look forward to seeing what that could be because, over time, I’ve read some really compelling middle grade books. Amber: Yeah. Things that have been coming out recently too are just amazing. Jeff: What’s the best way for everyone to keep up with you online so they can follow along with what you’re doing and when new stuff comes out? Amber: I always keep updates going on my website ambersmithauthor.com, but I’m most active on Instagram. On Instagram I’m @ambersmithauthor. I’m also on Twitter as asmithauthor and Facebook as well. So definitely keep up with me there. I love hearing from readers, and I just I get so excited when I see messages come in from you guys. Jeff: Fantastic. We’ll link up to all those places, the books we talked about, and of course, ‘Something Like Gravity’. Wish you the best of luck with that as this summer continues this year. Amber: Thank you so much.

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. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: 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%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, 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!

In today's podcast Mason chats to Jeff Chilton. Jeff has been working in the medicinal mushroom industry since 1973 and is an absolute specialist in his field. Jeff is the founder of Nammex, the leading supplier of organic mushroom extracts in the world today. With over 40 years of mushroom growing experience, Jeff was one of the first people to bring mushroom extracts to the North American market. All you medicinal mushroom nerds out there make sure you catch this episode, Jeff is a deep reservoir of knowledge and insight!   The gents wax lyrical over: The ins and outs of mushroom harvesting. The difference between products made from mushroom mycelium as opposed to their fruiting body.  Cordyceps Cs-4. The inferior nature of grain grown medicinal mushroom products. The nature of the medicinal mushroom industry at large, and what to look out for in regards to quality and authenticity. Following your passion in business. Retaining your integrity in the mushroom industry. Polysaccharides and betaglucans. China as a superior source Who is Jeff Chilton ?   Resources  Q: How Can I Support The SuperFeast Podcast?   A: Tell all your friends and family and share online! We’d also love it if you could subscribe and review this podcast on iTunes. Or  check us out on Stitcher :)! Plus  we're on Spotify and Soundcloud!   Check Out The Transcript Here: Time to talk tonic herbalism people. Maybe some medicinal mushrooms and philosophy for longevity, so pour yourself a tonic and get ready to get super human, baby. Let's start the show!   Mason: Hello everybody. Welcome back to the podcast. Got one that, I've been really looking forward to doing this interview. Jeff Chilton, I'll go into a little breakdown now, rather than just jumping ahead to why I'm really into his work. He's been in the mushroom industry since 1973. When it comes to mushroom cultivation, back then, he was really pioneering. Especially, a lot of the mushrooms that we have available today via cultivation in the west.   Mason: He had a lot to do with the developing the manufacturing of those. Then in 1989, switched over to the manufacturing of medicinal mushroom extract, so he's OG in this medicinal mushroom world. There was no real trending back then. And I, like him, we met two years ago at a herbal symposium in Oregon. That's when I really ... super aware of him and just how he was just via just his own integrity and just educating the market.   Mason: He became this internal watchdog of the industry. Just in the sense of just calling out real bad practices that are going on in the medicinal mushroom industry, and still today, and educating people, so you can spot a product on the market which is telling fibs, and really doesn't have the good stuff that we have all come to know and love about medicinal mushrooms.   Mason: So NAMMEX is his company, also Real Mushrooms, and I love the fact that we can sit down as colleagues, offering medicinal mushrooms, having more at it from the Taoist perspective and Jeff just rocking gin that specialization of mushrooms and especially being such an originator of the entire industry. I really love to be able to sit down, talk with him and ask him about the history, especially he's really been shining in educating people about the difference between growing medicinal mushrooms on wood and on mycelium. And we dive into nuances of that.   Mason: Basically we talk about the industry and we talk about setting up relationships in China and just how amazing it is to be able to source really incredible, the most high quality mushrooms that you're gonna be able to get in the world outside of a wild cultivated situation. Where we are talking about medicinal qualities. Getting those from China and being able to educate people about the beauty of getting them from China. We talk a little bit about that.   Mason: Also what it's taken for us to develop the relationships with growers and farmers and so I think you'll find it really interesting hearing me from 2011, Jeff from 1989 really navigating the difference in our stories. As well we go into organic because Jeff has pioneered in getting the first certified organic mushroom supplement in the US which is really amazing. We go a little bit into that, I share my two cents on where I see organic is at. More so the reason why I like Jeff is because he's not like most companies that just think the be all and end all is paying for this little sticker, jumping through a couple of hurdles and getting the sticker on your product.   Mason: But what we call going beyond organic. And Jeff does that with the organic certification and I share my two cents on where I'm at with that whole thing. But mostly just how much I love that he's non-stop out there educating people. Not just trying to flog a product, not just trying to grow this crazy big business. But I think that's kind of inevitably happening, it's just a nice slow growth of a business. Because it has a lot of trust and it has a lot of consistency in its messaging. And we talk a lot about that and have a lot of laughs and get a couple of stories about the history of the mushroom kingdom and those mushroom people back in the day. We talk about mushroom conferences and a bunch of other things. I think you'll really enjoy it, I hope as much as I did, here's Jeff Chilton from NAMMAX.   Mason: Jeff, thanks for joining me, man.   Jeff: Hey Mason, thanks a lot for having me.   Mason: Absolute pleasure, so remind me where are you again in the world?   Jeff: I am in British Columbia, Canada. I like on Vancouver Island out on the West Coast. You and I are actually connected by the Pacific Ocean.   Mason: Vancouver Island especially, for some reason that just keeps on calling in. I keep on having friends, awesome friends and now you. You're waiting there. And I'm like "What is the pull?"   Jeff: Yeah. You have gotta come. Definitely come in our summer time because otherwise you'll just be hit by all of those things you don't like, which is rain and all the rest.   Mason: Well, it brings mushrooms, yeah?   Jeff: It's true.   Mason: When is it really on for you there? What months is it on for mushroom harvesting?   Jeff: Mushroom season is really going strong in October. First couple weeks in November still happening but then things cool off too much then it slows down and there's nothing happening. We get rains in August, which really primes things then in the last couple weeks in September we could see things starting to pop up.   Mason: All right, I love it. October, that sounds good to me. Let's dive in a little bit because we met maybe we were chatting it must've been two years ago.   Jeff: At the American Herbalist Guild Conference in Oregon, which was just awesome.   Mason: That was amazing, I mean, we were in Silverton? Is that right?   Jeff: Silverton, exactly, yeah, that's where we were.   Mason: But apparently not the witch one. No, I think that's on the other side. Tony was looking at Silverton but that's where all the witches were.   Jeff: Oh, ah   Mason: That's a different Silverton. I can't remember the name of the hotel but their grounds rolling in and the ginkgo trees, big ginkgo trees as well lining it. And then all the herbalists who came and did their herb walks were just frothing at how much they were able to go and show everyone how to forage, how to identify. Because the array of herbs there was incredible. That place is designed.   Jeff: It was absolutely designed. It was a huge property and they put in all sorts of different plants, herbs and different kinds of trees. It was a beautiful venue there are a great place to have that. Even on the Saturday night when they had a band playing and everybody was dancing. I had a great time.   Mason: That's so good, yeah. I imagine that place gets a lot of herbal symposiums going through it. And man, the best thing, the fig tree was kicking. Did you get up there and face on the fig then, during that symposium? That was the best part of it. Right next to the pine.   Jeff: Oh my goodness, no. I hardly had a chance to get outside which is back to my place where I was staying on the grounds and then down to the venue. But I was locked into my booth most of the time and talking to people. And then in the evenings it was nice. It was a fun thing. And I know you said you had a chance to get to hear Christopher Hobbs while you were there. That had to have been really great because I always enjoy seeing Chris. I know he was really busy in fact, funny thing was Chris told me, he said "God, I'm sorry I didn't spend more time with you. I ran into an old girlfriend."   Mason: Oh, right, I'm happy for him.   Jeff: Me too.   Mason: You're like, 100%, I can't contend with that. So '86 Hobbs wrote the book. Were you aware when his book 'Medicinal Mushrooms' came out, because when was NAMMAX first created?   Jeff: I started the business in 1989. I'm trying to remember whether I knew Chris at that point in time or not, but he was part of the whole herbal industry, so to speak, and Herbalist Guild and all of that back then. I wasn't nearly as much in touch with herbalists until I started my company. Before that it was just pretty much just mushroom people and all the people that were in the mushroom world over here. There are a lot of them. Mushrooms really happening. Long before the herbal industry figured it out and got wind of it.Chris was one of the first because he was an herbalist but also was interested in fungi. So that was really cool.   Mason: Yeah, I think he studied and formally became a mycologist as well.   Jeff: Well, no, he was a botanist, definitely a trained botanist and a history orf botany in his family. Herbalists and things like that. And now he went on and he got a PhD in molecular genetics.   Mason: Okay, he's going down that route. I like that book because he was really able to balance the mystical aspects of the mushroom herbal kingdom especially and then dive deep down into the science. It's something that only him and Steven Hardliner. Steven is the master at going down deep, molecular how a particular compound is interacting with a particular viral passade. And then blowing into full throttle Earth poetry in the next paragraph. It's a real gift. Going back to the 80s, you were running with the mushroom clique in America. Yeah, tell us the story.   Jeff: The thing was in the 70s... Well, first of all in the late 60s magic mushrooms were really great interest. That was one of the things that I was really studying at university. I had this interested in mushrooms in the 60s and I reading all about a man named Gordon Wasson. Are you familiar with Gordon Wasson?   Mason: Just the name and loosely, but not really.   Jeff: Yeah, so Gord Wasson was a New York banker with a Russian wife. He learned about mushrooms being used deep in the mountains of Mexico by Curanderez and went down there in the 50s and spent the next five summers down there. He classified a whole bunch of different psilocybes during that period because he took a French mycologist with him. And so, five summers. But he basically opened up this whole world of Look! Still today after thousands of years there are people in the world that are still using these psychoactive mushrooms in their healing practices. Man, that was a mindblower.   Jeff: So I was reading Watson and other people that were involved in that and they had published these books that were incredible books. I mean Watson went on to publish a book called 'Soma: Divine Mushroom of Immortality.' He published that in 1968.   Jeff: Then somebody came along a man named John Allegro came and published a book called 'Sacred Mushroom and the Cross,' which talked about mushrooms in early Christianity. So, Mason, listen, think about it for a second. In 1968 two books are published. One says that a mushroom is at the root of Christianity. The other one says a mushroom is at the root of the Hindu religion.   Jeff: And then all of a sudden from there it just... You get going forward and you find that mushrooms, you see symbols of them and you start to hear stories about them used through all sorts of different groups throughout history. Pre-history actually, because as that came out people started looking and discovering this. That was really part of my study in university because I was studying anthropology. And mycology on the side.   Jeff: Going into the 70s in Olympia, Washington where I lived and worked on this big mushroom farm there was a whole core of people that were interested in mushrooms. It was an amazing group of people. Paul Stamos is one of those people. Ultimately he and I wrote the book called 'The Mushroom Cultivator' in 1983. We even had a group. We had four people, Paul and I and two other people, where we had four different mushroom conferences. These conferences were so ... You would have enjoyed it so much. We had people there that were speaking about how to identify mushrooms. I was speaking on cultivation of mushrooms, speaking on the anthropological aspect of mushrooms. We had great people there speaking. There was Andre Wyle was at our conferences. And it was just a great time had by everybody, right? You can imagine. All these mushroom people coming together. 200 people coming together for a weekend. Amazing.   Mason: So good. I mean, it's different, you got this original crew, there's always something special when you've got the original crew.   Jeff: Yeah.   Mason: There's a medicinal mushroom symposium every year that moves around the world. It was in Colombia a couple of years ago and then in Italy. Do you know that one?   Jeff: You're actually talking about the International Medicinal Mushroom --   Mason: Conference?   Jeff: Society IMMS and you know what? And that was more of a scientific group that was formed much later. I know the principles of the group. It started somewhere around 1999. They're having a conference in China on the 18th of September this year. You should come. I'm gonna be over there at this conference. I know lots of other people are gonna be there as well. It's gonna be an interesting time. I'm gonna be giving a paper there, which will be fun. There will be lots of other people too. I don't know what time of year you go to China.   Mason: Yeah, I go in September. I think this year we've got our staff retreat in September. I'm gonna check the dates, but otherwise I've been wanting to get along anyway. I've been trying to revolve it around going to Wudang mountain and doing some Taoist training as well. This is where I've been tossing up this year, what time to get over there. But that sounds a bit serendipitous.   Jeff: Yeah, well, the conference is I believe the 18th to the 22nd of September. That's normally kind of early for us. We like to go over more in November. We go every year. November's really harvest time for a lot of mushrooms like Shiitake, Maitaki, Wood ear. A little bit later is Hericium, Lion's mane. In September it's the Reishi harvest.   Mason: Yeah, Reishi harvest is normally for us in September. Where's your Lion's mane growing? Which region?   Jeff: It's growing in Fujian province.   Mason: Okay. Ours is a little bit earlier, in September as well. In Heilongjiang. In the northeast.   Jeff: Okay, yeah, because in Fujian province it is late, late November when it's quite cold. It's back to the mountains, quite cold. Maybe up in Heilongjiang it's colder in there right?   Mason: It's chilly.   Jeff: (laughs)   Mason: That's spoken like a true Australian.   Jeff: Let's fly in and start up north there and step off. I just can't wait to get to Yunan province.   Mason: (laughs)   Jeff: I can't wait to get down into that tropical vibe. Although, nothing beats that crisp air.   Jeff: Well that's good. I'm at that point where -- I don't know when your periods of this business growth have been -- but I've been real head down, bum up in the business. Not really been in that space of upgrading my information. Of course, I'm always reading and everything, doing all these things. I feel like that's like, you're at a point in your business where you are traveling around and you're educated. You're back at that point where you're free to go and educate and then go and educate yourself non-stop, constantly, which is really nice. I'm nearly back there.   Jeff: Yeah, you know what it's like. We are so swamped right now. We've got so much demand for the product right now. We're growing and over the past two years we've hired four people, two people for lab and another person for regulatory and, can you imagine, we've got one person that's strictly regulatory affairs and deals with all the paperwork that we have to deal with. The paperwork is really monumental. We get forms from companies that are 220 questions!   Mason: Companies that you're doing business with and they wanna know, looking at purity or is it you getting stocked with them that they want all those questions answered?   Jeff: No, they qualify their suppliers. And so this is all about GMPs for the most part and how your product is manufactured. They want to know that everything is according to the GMP, quality, and the standard operating procedures and all the rest.   Mason: I think that's where Real Mushrooms. Was it your son that created Real Mushrooms?   Jeff: Real Mushrooms, yeah. Sky created Real Mushrooms in 2015 as part of NAMMAX so it's just one division of the company. He runs Real Mushrooms as well as other things because he's in training to allow me to go fishing and he can stay and do all the work.   Mason: Great. NAMMAX is providing more providing bulk for people that are putting it into products and stuff?   Jeff: We're a business to business. We sell the raw materials and then Real Mushrooms is retail products and mostly sold online. Maybe getting it into the stores at some point, but right now an online business. But we're business to business where we sell to companies that then put the raw materials out under their own brand.   Mason: Does NAMMAX do... I'm increasingly aware because I think NAMMAX... we get a lot of people asking at SuperFeast but we don't really specialize in that B2B space. But one thing I want to talk a little bit about later is a lot of people who, like NAMMAX has bridged it and made it really accessible. Especially with you and the middlemen not having to deal straight with trying to... I'm still appreciating, it took me quite a few years but you'd know the in's and out's beyond what it's like developing relationships, critiquing, getting the authenticity on the testing. Also developing a relationship based on integrity and qualifying on that level takes so long. I feel like NAMMAX has really made it possible.   Mason: I know a lot of people in Australia who are like "Ah, great, I can just go and NAMMAX can just do it all for me." Which is really great, because there's a lot of people. I like it because there's a lot of people jumping onto the bandwagon, and Australia has got this nice buffer. We don't have too much shit here, which is really good. And that's something that's nice for me to be able to say about my competitors as well. Australian community doesn't need to be as wary, I think, as the U.S. world because the U.S. is a bit...I didn't realize it's a shit fight. I know talking to you a lot back in the day, I don't think I presented that I was from SuperFeast. We were just talking about mushrooms and I was just learning a bunch off you and learning about your history.   Mason: As a company when I started out it was an absolute no-brainer that we weren't gonna use fillers, that I wasn't going to be using mycelium product myself. We'll talk about that, it has its place. Of course, growing on good-quality wood. In Australia we're just small companies. I started in Mum's spare room getting products for me and Mum. Then talking to you I was like... and then reading your blogs and really falling off the back of it just like that. Wow, because you actually really inspired me after that talk going, "Well of course, I do talk about the fact that we don't use fillers and we don't grow on grains." And all these kinds of things, but it was getting to that point I didn't realize people really needed to know the in's and out's of your product and be able to ...   Mason: After seeing what happened in America with how much trickery there is and the percentages of polysaccharides there is, lets' go into it a little bit now. You've been watching it and been the internal watchdog of the industry, which I really like. When did that first start cropping up? When did people start jumping on the mushroom bandwagon and fibbing about the levels of polysaccharides and active ingredients?   Jeff: The interesting thing was that having been in the supplement industry since 1989, the key thing for me was that I was a mushroom grower by trade. So i spent ten years as a commercial mushroom grower on a very big, big farm. Not a hobbyist growing in my basement or a closet or something like this. A commercial mushroom grower, large farm. Millions of pounds of mushrooms every year. So I knew how it all worked, I knew the economics of it all. I realized back in the late 90s, for example. Or even the early 90s that you couldn't actually produce mushrooms in North America and turn them into a supplement, because it's a dry powder it's not a fresh product. Once you dry that thing out it's 90% water you gonna get ten times as much money for that pound of mushrooms. It doesn't work in the supplement world.   Jeff: That's where going to China and I went to farms, I went to factories, I went to research institutes, I went to conferences. The 90s was just amazing to see what was going on. I went north to south, east to west. Yunan province all the way up to Jilin province. It was all over China seeing this industry and seeing the research. One of the things, you talked a bit earlier about quality how do you know. Here I am visiting these companies going to all of these conferences. I'm having people coming up to me all the time saying, "Will you buy my product? Here it is." And they just show me a brown powder and I'm just like, it's a brown powder, I don't know what it is! How can I really know what that is. And then getting to know companies and people that were genuine and you could go to their factories and see what they were doing. Especially if they were only producing mushroom products and then building the relationships to that.   Jeff: Then I turned around and back in the United States here are these companies that come along and they start to produce mycelium on sterile grain. The worst part about it is they sell it as a mushroom.   Mason: Some people might not know what, so, we're talking about the fact, which you alluded to, which I completely agree with, that the only way to make a viable super high-quality product that's a powder is doing it in China. Based on the fact that, say you have 10 or 20 kilos worth of raw product that's gonna then give you a kilo of the powdered product in the end, it's not viable in the U.S. so to make it viable in the U.S., the way it generally works is that it's grown on a grain substrate, like rice, brown rice, oats, this kind of thing.   Jeff: Yeah, and the thing is, what people need to understand is that a mushroom is just one part of this fungal organism. So the other parts would be a spore, the spore germinates in to a fine filament, those filaments come together, they create mycelium, which is the actual body of the fungus. Which normally if you're out there hunting mushrooms you never see that because it's in the ground or it's in the wood. So most people are unaware of that. But that mycelial network amasses nutrients. When the conditions are right it produces the mushroom. That's what we see because up it comes and it's like "Wow, look at that thing there!" And then that matures, it produces spores, and then we have a complete life cycle.   Jeff: The interesting part, Mason, is that growing mycelium, which is the vegetative part of this organism, on sterile grain as a mushroom grower, what that is and what that was developed as mushroom spawn. Which is like the seed that is used to grow mushrooms. Because mushrooms don't have seeds they have spores. You don't plant spores when you grow mushrooms, you plant live mycelium. The mushroom growing world, what they developed is "Okay, we'll take that live mycelium and we'll put it onto some kind of a carrier. Then that carrier we can spread into our compost or whatever it was that they're growing their mushrooms in. If you take a gallon of grain, you've got maybe thousands of grains in there you coat that with mycelium, and then you take those thousands of grains and you can mix them into a big pile of straw or compost or something. Each one of those mycelium grows off of and it grows into this thing. So that myceliated grain actually was developed in the 1930s as mushroom spawn or essentially seed to grow mushroom.   Jeff: It's an easy process, it's done in a lab and people in the United States, we can't grow mushrooms. Why don't we just take that process, we'll grow out the mycelium. Mycelium in and of itself it's got beneficial properties because it is a fungal hyphae that has beta glucans in its cell walls. If you grow it in a certain way like in liquid or something it can produce certain medicinal compounds. But when you grow it on grain and then you don't separate it out from the grain at the end of the process you end up with mostly grain powder. That's what companies started to do. They started to grow the mycelium on grain. At the end of the process they would dry it -- just like you're drying a mushroom, but -- they'd dry it, they would grind it to a powder. No mushroom there at all. No mushroom, it's just myceliated grain, and it's mostly the grain powder. Finally, the worst part about it is then they call it mushroom when they sell it.   Mason: I definitely know I've been surprised, because my first trip to the States I went and bought all the different brands. I was floored by some of the grainy non-mushroom powder that I was buying. That was like white powder, it's in your face.   Jeff: Yeah, white powder and you taste it and you're like, "How's it supposed to taste like mushroom? It tastes kind of like flour."   Mason: Yeah, it's like flour, sawdust. So are there companies doing a mycelial growth that are more on the ethical spectrum, that they're not doing a full grain wash and that they're growing on a particular grain that they're able to separate out a lot of the mycelium? I know that a lot of the mycelium is embodied grain. That's just a reality that you're not gonna be able to get rid of. But I'm trying to play that... is that possible in your experience?   Jeff: In China they grow mycelium in large tanks of liquid.   Mason: Like Cs-4 Cordycep, yeah.   Jeff: Yeah, Cs-4 Cordyceps. They've been doing that for 50 years. But the thing is that it takes a lot of money to put in a big facility that can grow and these tanks are huge and you have to have a steam generator. It's a big investment but to actually grow out the mycelium on sterilized grain does not take a lot of money, it doesn't take a lot of expertise. It's a very simple process. Anybody can do it. In my book that I published in 1983, it tells you how to manufacture mycelium on grain at home in your kitchen. It's not difficult so it's very easy and ultimately, the stuff is so cheap to produce. And these people are selling it as mushroom and making a fortune doing it. It's really immoral in my opinion, and unethical. And especially if you're calling it mushroom.   Mason: I think because we sometimes maybe look at the market and what we subconsciously are looking for when we want a mushroom and most of the studies have been on if you're like... Most of the time we're looking for a fruiting body. That's the mushroom. It's the unspoken that we know that we're talking about is the fruiting body there? And I guess there are some companies that have been quite averse or trying to sign typically validate the mycelium. When I was first kicking around all this there were people going "Look, just have it all. Have the fruiting body, have the mycelium, have all these..." and I very quickly, before I had a company was like "Mmm, no." I'm not in this to justify a particular aspect of the market or go for ease. I'm in it personally, and especially in the beginning, being a dreadful romantic, trying to connect to a herbal system, particularly Taoist tonic herbalism for me.   Jeff: Exactly. The people who grow those products and they say "Oh, we want to have all parts of this. We want to have the spore, we want to have the mushroom, we want to have the mycelium." It's like they say "It's full spectrum." Well, the problem is that they leave out the fact that (A) there is no mushroom in it, and (B) the grain! How can it be a full spectrum product if they've got all of this grain in the product? That's what they don't like to talk about. They don't like to talk about the fact that it's mostly grain and all of this other stuff about "Oh, you know, the fruit body's in there and the spore's in there." Absolutely not. It's really a lot of smoke and mirrors.   Jeff: That's what's so hard to take is that when there are people out there actually espousing that and claiming that they've got a full spectrum product when in fact it doesn't take much in the way of analysis to prove what they do and they don't have. We've run analysis and what's really interesting is if you analyze it, for example, with a proximate analysis, which is proteins, carbohydrates, fats, ash, minerals. Those products line up perfectly with the grain they're grown on.   Mason: Are there exceptions to that?   Jeff: No. All of these products and there, it's the myceliated grain products. If it's grown on brown rice it lines up with brown rice. If it's grown on oats it lines up with oats. Literally the two lines run together. The way I like to think about it too is I talk to people and I tell them what they're growing is tempeh. And they say what tempeh is, it is cooked soybeans with fungal mycelium grown on it. If you look at that tempeh and it's all white that's the mycelium but if you look at tempeh and you cut it open you can see it's mostly the soybeans. And if you were to dry it out, look, Mason, mycelium is 90% water. Just like a mushroom. The soybeans are 50% water. When you dry that tempeh out the mycelium just goes "Fffft!" Just tell me, where's the mycelium? And you've got all of these dried soybeans and you're like, well, it's mostly dried soybeans, that product.   Mason: I'm sure you get it a lot as well. Yours, there's obviously a few brands in the U.S. becoming more aware of the others. I didn't go looking for them but as you move into a market. SuperFeast, I spoke to you about it the other day. We've got so many people ... like [inaudible 00:29:50] story. I've realized in business a lot of the time it's like, same with you, I like the people. I like the unique stories. People are like "Bring SuperFeast over, there's no one doing that like what you're doing over there!" I like, yeah.   Jeff: (laughs)   Mason: And it's the same. When you're upfront about the nuances although there's a lot of companies doing medicinal mushrooms like yourself and Taoist herbs like us, medicinal mushrooms. There's nuances there and the sourcing and there's nuances in the story. What I like is, which is going to get to the polysaccharide claim, and the full spectrum claim for the people growing the mycelium. Because people are in an egoic, competitive make money mentality a lot of the time. They think they have to be everything to everyone. Versus just being very upfront. I'm always quite upfront, I don't really look at that. I don't try and standardize color or anything in any way. I don't try and standardize the constituents. I don't even sell on the percentages of constituents. I don't focus on it. I'll move more in that direction because more and more people want to be satiated. I can say yes, we test for percentages of the active ingredients to ensure that they're in alignment with the Chinese cornucopia and ensure that they're actually active. And all that kind of stuff.   Mason: But going over into the States now and hearing about all these other brands and I'm with you whenever it's growing on grain I can't get behind it. Not to be disrespectful, and I'm always trying to be really amicable in my talks. There's a place for it, but less and less can I find that place.   Jeff: And I understand what you're saying too because if a person is genuine. For example the herbalists, who are at an American Herbal AHG conference. These are people that want to provide good products, they want to provide a body of knowledge to help people. That's who you wanna be, that's who I wanna be. I'm not in this to make a lot of money. I'm not in this to build some big company and go Oh, gee, isn't this great? Because I'm selling $20 million a year of this or that. That does not excite me at all. That has no meaning for me. What has meaning for me is that I'm producing a quality product that I've been working on for years and I can tell you the product is what I say it is and I want it to help you. I want you to be able to take this product and feel confidence that you're getting what the Chinese have used in traditional Chinese medicine for thousands of years. That's what I want.   Jeff: I don't want to sell you something that is not what it really is and is a placebo and expect you to buy the product from me and I walk away going "I'm managing this great at my company. I'm making so much money and it's wonderful." No, I'm sorry, that's not me. I'm not interested. Those people turn me off. It's like the difference between being in a group of people that really understand mushrooms or herbs and being in a group of people that are just talking business and numbers and all that kind of stuff. And I don't give a shit about that.   Mason: Yeah. I think it's interesting. Watching your business I can see in the beginning it probably would've started out that everyone knew Jeff and knew your level of integrity and how you just wanted a good product. In that little circle it was like 'Great, we'll just go and get Jeff's product.' Then as you grow I think what you've done really well ... just to put it as an example of why I'm bringing this up, we're getting to this point where we're growing as a company where it's beyond Mason at the markets and everyone knows that Mason has the badass tonic herbs. Or people are coming along to the talks and all the health clique. We've started emerging.   Mason: I think you would've gone through this years ago when you emerged beyond the health clique. And it's very dramatically people aren't associating directly with you or the founder, it's the company. They don't even know or care who the founder is and therefore you need to have these things in place. We're getting to the point where everyone who's a SuperFeast customer is just like, "Yeah, we don't even care about organic, we know what you guys are doing," and we're going on that old philosophy and we're documenting that and there's all those other checks in place like independent testing for pesticides and metals and all that in place and available.   Mason: But it's getting to that point now where the people on the very outside... I still don't know if we're really gonna shift because I still personally don't care and I don't change my company for perception's sake. But you can see Wow, that organic would be really, really useful for those people on the outside. Or the testing to know what percentage of what's going on inside and being able to present that. I think we'll move in that direction. I think you've done that really well and really maintained the trust in the brand of course, and in yourself. But maintaining you there as the one that's rolling this along and not then just relying, you know, the organic certification or the percentages.   Mason: I think that's what I find really commendable, because most people then they rest on their laurels. Once they change over into, not standardizing but testing for minimum constituents like beta-glucans or organic. they then rest on that. Whereas that means nothing to me at all. Being able to talk to you I'm like, Yeah, because organic, I don't know what your take on that. I know there's some terrible organic products out there. Just the fact that we know we can go organic there's five different companies we can go to, so you just go and find the company that suits you. We can go with the company that's the hardest to jump through.   Mason: I won't go into the details of what's going on, why we're probably not going to go in that direction. For us there's so many little micro-farms that we're being nimble with whom we're working with. When we're beyond mushrooms we've got a lot of other herbs going on. We need to cut that farm out if they need to move on and do something else and we'll go and we've got that team to go around and constantly go and find these people. So every time we want to nimbly adapt and go down a different direction when someone's doing a little more traditionally than the other person, all right, get the organic certify up. Or lie, which is what I think a lot of people are doing. They get the organic certification, then when they change up those little farmers, because we're dealing with independent farmers as well, not a company that can provide the organic certification. I don't know why I went on that rant. So that's why we're not going on down that route.   Mason: It's something I see. I know there's a bunch of companies who are coming to NAMMAX, which I think is just been so good for the Australian industry. For people to know that they're very quickly going to be introducing a really good quality. You can tick off the organic but I hate it when it's just organic that they are going for and not just an incredible product with a story behind it as well. So I really commend you for offering that out.   Jeff: I've always really believed in chemical-free food. Organic is more than just chemical-free it's how it's grown. When you're growing out of soil it's building the soil and not just depleting it. For me organics is a holistic way of looking at things. I've always considered that to be very important and I support that type of agriculture no matter what it is. A lot of these companies that are producing myceliated grain, they're organically certified!   Jeff: It doesn't necessarily mean that it's going to be a great product. These companies have what I call all sorts of merit badges. 'We're big and we're organic, we're kosher, we're this, we're that,' which ultimately means nothing at all. There's a lot more to it than just that. The one thing I really like about what you're doing too is that you're introducing the philosophy of it and that's something that you really believe in. That to me is important and that's what people look at. They look at who's behind the company and what that person has to say, is that person ethical, righteous, person or not. You're not up there as a smooth talking business salesman or anything like that, right?   Mason: You should see me try and sell something I don't like. I'm a bumbling mess. I think I told you that back in the markets people used to say god-made...you could sell ice to the Eskimos. But I'm terrible if I'm not talking about herbs or philosophy behind it.   Jeff: That's because you're doing something you believe in. That's where everybody should be. Not everybody has that opportunity, but if you can have that opportunity. I was lucky enough that I followed my passion and I didn't do that because I wanted to be rich. I did it because I loved it. I always say to people, if you really like to do something, whatever it is, just do it. Follow your passion. Maybe you're going to be poor for a long time. Make something that you feel good about.   Mason: Honestly, and I really mean it not just because you're on the podcast talking it up or trying to flatter you. But when I met you, you had a happy disposition to be in business that long. In the beginning I was trying to escape the business side of things. Quite scared about having a business and not coming out the other end alive. You have a sunny disposition and you still have control of your company and the standards and you're still educating about the same thing that you're educating, of course it's evolved, but you were educating about beforehand. And there's something that I've learned a bit about in that. There's something humbling and nice about not being in that pursuit for aggressive growth while still growing at a nice, sustainable rate. But staying true to what you were doing in the first place. I educate about basics of herbalism and medicinal mushrooms in the beginning and then I'll move on and doing other things. The more I go along the more I want to settle back into doing what I did all along.   Mason: I've got a weird thing about going back to the organic, I'll almost shy away from something if it's organic because I see it as a marketing ploy a lot of the time. And I think it is a lot of the time. With little things. When growing Lion's mane there's a lot of people who will use organic fungicide because they don't pick when they're watering out to the Lion's mane. I like to use this example because we don't have a plastic covering, it's just a straw and a hut to keep it nice and dark and it gets watered. That's the only part that gets watered. And one of the things I talked about in the beginning with Lion's mane, I just heard about it through the grapevine, that fungicide is needed if you're watering straw a lot of the time in order to, all right, we know why fungus grows. But found someone who wasn't doing that and found people who were doing organic Lion's mane who were using organic fungicide on the huts. Little things like that they get me so dejected about the marketing ploy behind it. But I think you're the one organic product that I would be over the moon to use.   Mason: And the other example is Ron Teeguarden. I think we talked about him. He was such a rogue in the industry herbally. You were telling me about the acupuncture when he was offering acupuncture because he's a barefoot herbalist and all the acupuncture's guilds are like "Screw you, you need to be regulated." And he's like "Hey."   Jeff: I know, it might've been somebody when you were in LA but it wasn't me. I don't know Ron that well. He's been around a long time. He's done his own thing, he's not out at the shows or anything like that. He's very well-known and in a sense he's been the herbalist to the stars. He's in Los Angeles, right? A lot of people in Los Angeles that are into herbal medicine and living properly in term of what they eat and things like that. They would go to Ron and Ron has one of the very first herb bars where you can walk in and have this type of a drink or that type of a drink. He was really in it very early and doing stuff that nobody else was. He was an outlier in that sense. I don't think he really needed to go into the industry proper. He's done a little more now that before. He didn't have to.   Mason: He, on the level of sourcing philosophy. I bumped into him years ago. I was at that place where I was starting to grow, people are asking why I'm getting my herbs from China and people asking me if I'm organic and all these kinds of things. I want to keep on doubling down on my philosophy, what I'm doing here. One thing that I drew from yourself as well and then be proactive and educating the market. Not in pushing your own product, just generally being happy about the market being educated as well. And Ron was like...In fact I talked with him for about five minutes. More or less he was like "Listen, if you have that spark," I remember, "do not deviate from that sourcing philosophy." And it really stuck with me and from that day I did. I doubled down and I was not going to try and... I'm going to continue to not worry about what's going on and just do me. It's a lot of fun. I was at Dragon Herbs Tonic Bar about three weeks ago. I frequent the Hollywood one when I'm in L.A.   Mason: Before we go too far off the mycelium grown, one of the things you've really educated, not only the market, but businesses in the market around medicinal mushrooms in the market, is how to identify a true polysaccharide read on medicinal mushrooms. Rather than people including 60% polysaccharides or even 30%, yet when you go down into the class of beta-glucan it's actually been tested you've been hoodwinked and they've gone dry from age or whatever. Can you talk a little bit about that?   Jeff: This is something in the herbal industry too that you learn right away, and I learned it back in the 90s, was that so many herbal extracts, when you make the extract they oftentimes need some kind of a stabilizer. Otherwise they can get gummy, they can jut come together if it's a powder. Putting a carrier with a lot of extracts was pretty common. What happened was sometimes companies would cheat a little bit. The next thing you know instead of 10% carrier it was 50% carrier or 80% carrier. And they're not revealing that to anybody. You think you're getting an herbal extract, not just mushroom extract, an herbal extract and it ends up being mostly maltodextrin or dextrose or something like that, and they're not telling you, then it is really deceptive. So there's a lot of companies that were doing that in the industry.   Jeff: As I went along, the whole time that I'm working with people in China I'm like, "Look, I want extracts where we aren't using any carriers. It has to be made in a certain way," because I'm looking for the pure essence. In traditional Chinese medicine they take the herbs and they throw it in a pot and they boil it up and pour it out and "Here, drink this!" There's no carriers in there.   Mason: That's right, not sliding agents.   Jeff: That's right. If you have to put something in a capsule you've got 150 milligrams of different types of fillers and binders and flow agents. Putting it into a pouch is so nice because then you don't have to put those things in with it. It's just the pure herb. Early on in the 90s everybody's testing for polysaccharides and nobody's testing for beta-glucans. And beta-glucan is a polysaccharide. Unfortunately all these carriers are polysaccharides too. A lot of people can hide that from you that you've got carriers on their product. No, no, we don't use carriers, it's 100% mushrooms, stuff like that. That's where with any kind of supplier you have to build up a level of trust. Like I say, they show you a brown powder and say. "Here's our product, it's shiitake mushroom extract. Isn't it great?" You can test it.   Jeff: This is the thing, Mason, it's not like you can take a mushroom product other than a reishi extract, consume it, and then a few hours later or a day later go, "Wow, yeah! Did I ever get a kick out of that!" No, it doesn't work that way. You can organoleptically, I can taste the shiitake extract and I can tell you yeah, that's definitely essence of shiitake. Or with reishi it's so bitter I can taste all those bitter notes in that reishi extract, that is an awesome extract.   Jeff: I used to give a reishi extract to a friend of mine who was a deep herbalist making his own liquid extracts and a big business ultimately. He'd taste some of my extracts in the beginning and he'd go, "Not bad, but it tastes a little bit burnt." And I'm like, "Oh shit." When it was dried it was maybe in the oven a little longer, and he could pick up on it. I thought that tastes pretty good. That was in the early days when I didn't know any better. I thought it's great and high triterpenes and all this. He'd go "Yeah, it tastes a little bit burnt." Those kind of things teach you a little bit about, okay, how's it made. Let me tell you, in the 90s the facilities that were making herbal extracts were nasty. They were old facilities   Mason: Not too much GMP regulation back in those days.   Jeff: It wasn't like stainless steel everywhere, no. Everywhere was dark from all the herbs they'd been cooking for who knows how many years. Now all that's been torn down and you see nothing but brand new factories in China. Everything is stainless steel and it's beautiful and there's none of that anymore. But back then, actually, it wasn't until we got the megazyme test and I started using that. And that was in 2012 or 2013. Up until that point I thought, well, the polysaccharide number was high, that's great. Then we starting testing the products and that's where we really pulled back the curtain. My main supplier, awesome! The test results we got from that. Beta-glucan and alpha-glucan and the alpha-glucan, that was where any of the carriers were revealed.   Jeff: And then another company that was supplying me with some products, only a few, not many, fortunately. And was swearing up and down they never used any carrier. Jesus, their alpha-glucan level was way up there. I was shocked and really upset because I thought their product was good because occasionally I'd test it for polysaccharides it was 50-60% and I was thinking, great product. I could taste it, it tasted okay. Nothing but mushrooms they were producing. But here they were. They were putting them on a carrier and telling me they weren't. That's the kind of thing that you face when you're over there.   Jeff: How do you qualify these products? You can go to the factory. They can show you around, you can look at all the mushrooms in their warehouse, you can look at them cooking these things up, the final products. They don't show you the bags and bags of maltodextrin that are hidden back in the warehouse somewhere that they're using as a carrier for the liquid extract. That literally pulled back the curtain and I went and confronted that with them. They claim no. Finally they actually admitted it and I'm like, okay, see you later. I'm not buying another product from you because you lied to me. Fortunately it was a secondary supplier. They weren't my main supplier at all, but I needed a secondary supplier. I visited them and it was all mushrooms that they were doing and they were in the heart of mushroom country and it was nothing but mushroom. Yet they had all these carriers in there. I was really upset not only with them but with myself because I got taken in by it too. And that's what you have to do.   Jeff: Look, Mason, have you ever been at Ali Baba and looked at all the mushroom products being sold?   Mason: It's always funny, and as you know, everyone's jumping onto the bandwagon right now. You can see people trawling through Ali Baba going "Oh, just tell me which one is awesome." I haven't been in there in a long time. I got curious, to be honest. I think we were in the office having afternoon drinks and seeing what was on Ali Baba. It is insane.   Jeff: It's totally insane. So many companies selling mushroom extracts. Sometimes they're selling at prices where you're like, "No, wait a minute, you can't sell me that extract for $20 for a 10:1 extract. That's impossible. You load it up with starch, that's quite possible, right? That's where analysis, for me, has been very helpful. Especially the beta-glucan analysis because that gives me that alpha-glucan which is the whole carrier. That's what unmasked all of those myceliated grain products. There's definitely a place for analysis. There's also a place for getting to know the grower. I don't believe in organic pesticides. I don't give a shit. Don't use whatever it is, you have to grow this. I know it's more difficult but you have to grow this without sprays and all that.   Jeff: The thing about China is that when you're traveling through China and I've been back in the mountains in all these different places and you go back and you look down and this little valley and here's this beautiful rice fields down there and you're going "Oh, isn't it great, back here. Everything's idyllic." And then you see somebody walking through the rice field and they've got a backpack sprayer. And they're going along spraying chemicals on this rice crop. I'm like, "Ugh, shit. Really? Do you have to do that?" And I think to myself, even the smallest growers out there are using some chemicals. That's where I'm like... And I want to be sure. And that's where we test and test to make sure that everything is staying on track because these things can slip in. Somebody can cheat. You have to ride herd on the whole thing. Otherwise it can slip right through your fingers.   Jeff: That's been good for me in the sense of having an organic product that has meant that we put these constraints on the people that we work with. We say look if your product shows one of these things in there I'm sorry we're not selling it. If you and if you shipped it over to us and we find it in there after you've done the testing that's all good and we find it in there it goes the landfill I'm sorry, we can't sell it. That has been a really good quality, that's how we keep that quality up. In that sense I kind of believe in it all and think it's important. It helps us keep the product a little bit more real.   Mason: As you say said there's all these things that can go by... even though it is organic, you can get organic pesticides and all this kind of stuff. I have taken your product and of course I really love it. You know that you're going to go that extra mile with it. It's a trip around it, there's a stigma around China is isn't that whole thing polluted?   Jeff: Well, that's the other side of it right now, Mason. People are so afraid of anything coming out of China that this gives them a little bit more confidence in it. They can say what they want about organic and all but we've got pesticide tests that can demonstrate what it is and of course the always have to do heavy metals and micros and all of that.   Mason: Alpha-toxins   Jeff: For us, especially as a raw material supplier to companies large and small we have to be able to give them confidence because you know they're selling a Chinese product that they buy from us and lot of people are just like you know when it comes to China it's like no no no no it's like not going to do it so I have to talk to a lot of people. And I say, well, hey look. There's products in the United States that are absolutely full of chemicals. So it doesn't matter where it's grown. It matters where it's grown but it's not this country or that country. You can grow good, clean products anywhere in the world if you're doing it properly.   Mason: It's so good. Of course people are realizing that the ultimate Chinese herbs and medicinal mushrooms are going to be coming out of China. I really like how it's still dominating and making it really easy for people to get One thing that's organic and Two very quickly have all those things to provide so enough people are going to be able to go, Oh, okay, so it's from China and we can trust it. That's something that makes it really easy, because people are going to jump on the mushroom bandwagon. We found it as well, a similar thing. People want to come, they're like okay, tell us about Chins. Okay, tested three times for pesticides before it comes to market, each batch. Plus here in Australia the TGA facility and heavy metals and alpha-toxins and microbes. At some point people go "Hmm, shit, okay." And testing of the water. And when we can going and doing radiation testing in the areas. And then going live and seeing pictures of you at your reishi farm is magic.   Mason: When I was going live around China going, you know we're still going up while we're outside the mountains going to the fields where the eucommia bark trees were grown or up in Yunnan. Just drove five hours in the middle of nowhere to get to the poria farm, where there's wild pine and people are going "Holy shit! Look at that land! The land of the dragon. It's calling me. It's real." All of a sudden popping that thing that first of all, yes, you just need to be vigilant, that's absolutely number one. I've only changed suppliers once. In the beginning I found someone I had really enjoyed their product. And then what I've decided was one of my areas in going forth is I need someone that could absolutely school me. If I'm requesting things and they weren't able to "bang" school me on that immediately, then I'm not going to be able to do business.   Mason: And it got to this point where I was confirming no municipal water. Only springs, only well water. Only creek water in the area. Nothing from the tap every touching the crops. At one point "Okay, sometimes that's a bit hard." I was like "All right, I'm gonna change now." That's when I started going down that route and ended up... developing relationships, developing a friendship first, understanding the intent behind the philosophy behind the business, understanding who owns the business that you're going to be dealing with and what their motives are and what their history is. These are the things where people don't realize what goes into it. People go "Can you tell me your supplier?" And you're like   Jeff: (laughs)   Mason: At this point it's not about me being scared about you having access to that supplier but so much has gone into this relationship. It's not just about finding someone and sourcing off them. Although, it's nice and easy to do that. If I was beginning right now I'd love to be buying just from suppliers on NAMMAX because it's cool. All the certificates, all the independents, and then all the years of vetting and tweaking that leads to this point where trust is inevitable and you become even more switched on to what to look for if anything ever comes up. If anything slips or changes you know the questions to ask and where the slip in quality could possibly be. And large ways you know how to put things in place that would stop that from ever happening to begin with. It's an interesting industry.   Jeff: We go there every year and we'll do an audit. We'll visit farms, the factory we'll be sure we confer with our partners to make sure everything is good. This year we're at the point where we're hiring someone to be on the ground in China that will do a lot of checking and stuff for us on a regular basis. More regular than us going over there once a year. It's gotten to a point where we really need that coverage of somebody right there that we can say "Can you go out to this farm or this factory?" Also, communications because sometimes communications... although some of our partners speak English but some of them not so well and then they have to use a go-between and that's not always the best. So we're gonna have somebody now that's right there in China and can do that for us. Can you imagine going to China and traveling around without having somebody with you to help you through the liaise and talk?   Mason: I have the best intentions of getting my Mandarin up to scratch and as soon as I'm out of it, it all slips out of my head. I haven't fully entered into that poetic language realm. The language is sticking. Can you speak Chinese?   Jeff: No, I speak Spanish, but Sky's learning Chinese. He has three classes a week, an hour each class with a Chinese speaker he does it over Zoom or something like that. He's very diligent about it. We get over there. He's speaking with them in Chinese and they love it. He's learning more, but unless you actually go and live somewhere for a while it's always tough. I've been thinking about it. You go over and spend two weeks, three weeks, whatever, then you leave. That's nothing in terms of really getting in and learning a language. That's swimming on the surface.   Mason: I gotta get onto it because I'm gonna do some Taoist training there.   Jeff: Yeah, that'd be really cool. You're young enough that you still can do that. I'm way beyond doing anything like that.   Mason: Come on, they'd love you up in the temple.   Jeff: Not only that, where I love to be is in Patagonia   Mason: Dude, that's the other place my heart lies, down in Patagonia. I want to become an old Argentinian man. I want to become a cowboy.   Jeff: Exactly, I know where we can get some horses, Mason, so let me know.   Mason: All right, that's it. That's on. China this year, maybe Patagonia next year.   Jeff: Yeah, two years ago Andrea and I went out and spent the day with, we had a gaucho that took us out. We went all over this one area. It was a hot day too. We were on horseback the whole time, cruising through, very slow. Slow living at its best, right?   Mason: Yeah, that's it. Drinking, eating a lot of meat, drinking a lot of yerba mate.   Jeff: Yeah, when you're on a horse you're not going to go very fast. You're going to cruise along. It's life in the slow lane.   Mason: I love it. So before we finish up is there anything that is coming up now that's exciting you about educating people about this market and about this industry with medicinal mushrooms?   Jeff: People really still need a lot of education with mushroom. Part of what I do too which I really like is I talk about the nutritional value of mushrooms. My thing too is eat mushrooms. I think mushrooms may be the missing link in terms of food. A lot of people are like, fungus, never eat it, right? And I'm like, "Dude, you've gotta get on and eat mushrooms, it's a fabulous food. They've got great benefits, you get medicinal benefits as well as nutritional benefits." That's the key for me, I'm pushing that really hard when I talk to people, saying "No, it's a fabulous food." And in China they have this whole thing of food is medicine.   Jeff: That's in Ancient Greece too. Food as your medicine. Everything that you take into your body should be something that is beneficial. And medicine as a very loose way in terms of it's feeding you and keeping you healthy. And that's what we should all be thinking about. What we consume is keeping us healthy and we should look at our food as that. That's providing me with all of these benefits. I say if you want a supplement, you feel you need more, that's great. You can supplement. But definitely use mushrooms for food. That's a big category for me.   Jeff: As a mushroom grower, can you imagine? I'm working on an agaricus farm. For ten years every day I'm going in I'm going through the rooms and each room ultimately is producing 20,000 pounds of mushrooms. There's mushrooms everywhere around me growing and I'm stoked. I love this. I've got mushrooms that I'm eating all the time. I've even got small beds of mushrooms that I bring stuff home and I'm growing them in my house because it's so interesting to me. The farm I was on it wasn't just an agaricus, we had a scientist that was growing shiitake and maikitake and oyster mushrooms. Back in the 70s when those weren't even on the markets anywhere. And I had access to these mushrooms. Besides the wild mushrooms that we were navigating. I'm like, make them part of your diet because it's a wonderful food.   Jeff: That's my message to people is this is a forgotten food, bring it home.   Mason: I love it so much. Thanks for reaching out, I really appreciate you reaching out and having you on here. It's not only do I admire you as a person, admire what you've done and your business. I spoke to you a little bit about it. I like talking to the other people who are perceived competitors. There's so much room in this market and everyone's doing their own thing and has their own story. This whole red ocean we have to fight over a scrap of people who are going to be buying mushrooms and not focusing on educating together is absolutely ridiculous. It's always awesome to meet people who trail-blazed that attitude in the industry. Calling out people that are bullshitting and then coming together and educating together and getting the world healthy together in our little way. There's something really nice about that that makes it possible to be in business for so much time, for so long, see so much shit yet still have such a positive attitude about it.   Jeff: That's absolutely right. I really love what you're doing too and I love the whole Taoist part of what you're taking to people and bringing to people. That philosophy is really awesome. That's what brings something really unique. When I hear you talking about mushrooms up around, what's the lake up there in the mountains?   Mason: Mumbai   Jeff: Yeah, that was so cool and you're hanging out there, talking about the mushrooms really excited about it all. That is really special. I love your energy, Mason, I'm really happy that we've been able to get together and have these meet-ups, speak and let's carry it on, let's keep doing it and stay in touch for sure.   Mason: Absolutely. We'll get some videos in another podcast together, 100%. I'll go check out these dates, see if I can swing a   Jeff: I'll send you the info on it so that you can check it out. If you can come you'll have a ball because there's gonna be lots of mushroom peop

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.

  This week, we’re excited to be focusing on a subject that we’ve mentioned quite a few times already on this podcast—the Enneagram. For those of you who haven’t been swept up in the Enneagram mania yet, it’s sort of like a personality test. But it actually goes deeper than that to show the motivations behind our actions and thoughts. To help us with this complex topic, we brought in a couple who knows the Enneagram well—Beth and Jeff McCord. Beth is the creator of Your Enneagram Coach, which helps introduce people to the Enneagram and connect them with a personal Enneagram coach. Her husband, Jeff, is the executive pastor at Southpointe Community Church in Nashville, Tennessee. Beth and Jeff have been married for over 20 years have two adult children. Interview Can you tell us about yourselves and how you got into the Enneagram? We’ve been married almost 24 years and have two kids in college. We started learning about the Enneagram in the early 2000’s. We were in the stage of life with little kids when you’re trying to live like Christ, but find your internal world derailing all the time. I wanted to be at my healthiest but was struggling. That’s when someone showed us the Enneagram and it helped me understand why I veer off course and what my healthiest was. We felt whatever tool we found had to be paired with the gospel. The Enneagram will tell you why you think, feel and behave in particular ways. Can you explain what the Enneagram is? The Enneagram has been around for thousands of years and used in lots of different sectors. It’s become more modernized with psychology since the 70’s and we’ve looked at how the tool can help illuminate our heart condition. I want people to realize that the Enneagram is a great tool, but the gospel is what transforms us. We’re always safe and secure in our identity in Christ, but sometimes we have times we’re not doing well. We want it to be a wakeup call to the patterns that aren’t best for or your relationships. Jeff, can you tell us about your role? I’m an executive pastor. I’ve been pastoring in the local church since 2002. When we started using the Enneagram as a couple, we started in the local church at our dining room table. Even back then, we would bring the insight of the Enneagram and apply the gospel to see hearts change. My beautiful bride is a type 9, who had a tendency to hide her talents, but she brought the depth to that conversation. How do your two Enneagram types interact? Jeff: Let’s start by talking about my love for ice—I love ice and cold drinks. Beth: We have a great ice story. I’m a 9 and our thought process is that we don’t matter—our voice doesn’t matter, our presence doesn’t matter. It’s a common theme for 9s. Jeff: I’m a type 6 and there’s a roaring committee of thoughts in my head all the time. Beth: For the 9, who feels like their presence doesn’t matter, when I do talk I want his full attention. When he looks at his phone what happens instantly in my mind is, “see, my voice doesn’t matter”. If I’m healthy I can navigate around that. Jeff: I often get a little impatient with her pace—9s meander in storytelling. So as she was telling a story one day, I decided to take a little break while listening. Beth: Jeff got up to get some water behind me and has a 32oz glass. The fridge is crushing ice into his Yeti and I’m still talking. He is getting his ice and I’m thinking: “see, he doesn’t want to listen to me”. Ordinarily I would shut down and stop talking and we start this dance and start to spiral. But that’s when the Holy Spirit came in and he’s told me time and time again that he is listening. So while he was still crushing ice, I’m thinking” “He loves me, we’re best friends, he’s just getting ice and it doesn’t have to spiral out of control”. And we’re able to move forward. Jeff: There are four things we hear from people as we talk to them about their dances: I didn’t understand my spouse and now I have clarity It’s compassion – I’m so sorry that’s what you’re feeling I understand our dance and our dynamics The Enneagram gives us great language to able to talk about it How does the Enneagram reveal both people’s strengths and weaknesses? The Enneagram is going to tell you like it is—blunt and straightforward. You’re going to see some things that are really hard to swallow. But if you’re able to recognize that Christ has already taken care of things, you can see these trouble spots and not be overcome with self-condemnation, fear and shame. You have to own it and ask for forgiveness but you’re able to do that because you’re already free. What are the benefits and challenges of each of your types? Jeff: There’s a book out there that talks about how we marry people who bring out a good we desire for ourselves. There’s something about Beth’s peacefulness, steadiness and sincerity that is very safe to me. Beth attunes to me in a way that brings peace and rest to my heart. I appreciate her strength, resolve, quiet perseveres and the attention she gives to me and our home. I want to be better at that because I’m not naturally at rest. Beth: The strengths that Jeff brings is absolute commitment and loyalty, hard work and being able to see what I miss. When you use this in marriage, your spouse cannot come through for you in the way you long for but Christ did. Everything has to hinge on Christ or you’ll be back in the ditch again. What have you learned about Jeff being a 6? Beth: 6s really need safety and security. They’re not all the same—my mom is a 6 and wants physical security (food, money, health). Jeff is more relational security. When we are in an argument and I withdraw, that is only saying to him “abandonment”. I’m not intending to do that to him. When I feel myself starting to check out I can say to him, “I know this is important, but I need some time to settle down and process”. That’s so much more helpful to me and communicates to him that I know safety and security are important to him. Jeff: The work for me is to believe it—that after 15 or 30 minutes she’s going to re-engage. And even if she doesn’t, I’m still secure in my relationship with Christ. It ends up creating a very hospitable dance between us. What resources do you have available for people who want to learn more? Jeff: This is going to be a big year for us. We’ve written a book called, Becoming Us: Using the Enneagram to Create a Thriving Gospel-Centered Marriage. It’s really the foundation to a number of other resources. We’re going to be releasing a new marriage assessment in June to help couples get an introduction to their dance and what they think about their dance and that’s going to be free. We’re also going to be doing date night events throughout the United States beginning in June. Those are going to be fantastic opportunities where we’re going to introduce the idea of the dance. Beth: We are developing 45 marriage courses. The reason there’s 45 is because there are 45 couple types. So there’s a course for you and your spouse and we’re going to specifically talk about your dance and get into your kitchen. Not only will we show you the negative parts of your dance but also the redeeming factors of Christ and what He brings. That will be coming out in June. We also have a free assessment if you don’t know your type. And then we also have Discovering You which is a cliff notes version of the Enneagram if you’re new to the Enneagram. If you know your type you can do Exploring You where I do pre-recorded coaching sessions where I break down your personality type into bite sized lessons. We’ll have 9 more books coming out in December—one on each of the types. Your One Simple Thing this week Get your Becoming Us marriage course and get insight into yourself and your spouse. Show Closing Thanks for joining us for the Married People Podcast. We hope you’ll subscribe to the podcast on iTunes and leave a review—they help us make the podcast better. We want to hear from you! Share with us on Facebook, Instagram or our site.  If you want more resources, check out the MarriedPeople membership or Ted’s book Your Best Us.  You can find more from Beth and Jeff at Your Enneagram Coach.

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 my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! 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 don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, 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 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

The guys talk about having more books than shelf space and also their upcoming 24th anniversary. Will reviews An Easter Promise by A E Ryecart. Jeff reviews Play It Again by Aidan Wayne. Jeff interviews Hank Edwards and Deanna Wadsworth about their collaboration, Murder Most Lovely, the first in the Lacetown Murder Mysteries series. They talk about how they came up with the book, their process for co-writing and what’s still to come in the series. We also find out what’s coming up for each of them in 2019. Complete shownotes for episode 186 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: An Easter Promise by AE Ryecart. Reviewed by Will. This is the continuing story of Rory and Jack, who we first met in the holiday story, A Kiss Before Christmas. In that story, Jack finds the homeless Rory huddled on his doorstep and offers him a place to stay. As they learn more about one another, Jack asks Rory to pose as his fake boyfriend when he goes home for the holidays. An unexpectedly severe winter storm prevents them from that trip, but in the few days they’ve been together they’ve fallen in love. I read A Kiss Before Christmas last year, and I still highly recommend it. In An Easter Promise, it’s now Spring and our two heroes are finally making the trip to visit Jack’s family in his ancestral manor house in the countryside. This is a particularly nerve-wracking experience for Rory, whose childhood couldn’t have been more different than Jack’s well-heeled upbringing. Things go relatively well as Jack shows Rory around the expansive estate, but they then get frosty when Jack’s mom makes it clear that she believes that Rory is after her son’s money. Gold-digging accusations aside, as a favor to her, Rory steps in as a last-minute contestant in the Best Bake competition at the village festival. Though his brownies were obviously the best, he doesn’t win. Afterward, Jack announces that he and his culinarily gifted boyfriend are going into business together and are opening a bakery. This once again raises the suspicion that Rory is only after Jack for his money, causing a major rift in family relations. Jack tells his mom where she can stick her suspicions, and is ready to return to London, but when Rory takes the family dog for a walk, he gets lost on the moors in a sudden storm. If reading fiction set in the U.K. has taught me anything, it’s that going for a walk on the moors is always a bad idea. The family organizes a search party and journeys into the dark night to find Rory. He is eventually found, and Jack makes amends with his parents. Flash forward a few months to the opening of the bakery and the beginning of a new chapter for our romantic heroes. I really like both of the stories featuring Rory and Jack and sincerely hope that this isn’t the last that we’ll see of them. The opening of the bakery certainly presents several new story possibilities. A.E. Ryecart, if you’re reading this, I’m a fan and a series set in this world would be greatly appreciated. Play It Again by Aidan Wayne. Reviewed by Jeff. I was completely delighted by new-to-me author Aidan Wayne’s Play It Again. Part of what drew me in initially is that part of it relates to what we do here on the podcast. Dovid is a YouTuber alongside his sister Rachel. They run a channel called Don’t Look Now. Among the things they do is review eateries in Seattle for how accessible they are because Dovid is blind. They also interact with their fans, go on trips, open mystery boxes–it’s the full YouTube gambit. Over in Ireland, Sam runs a Let’s Play channel where he plays a popular videogame. Rachel and Dovid become obsessed with Sam’s channel because of his easy-going, fun delivery. Dovid calls out Sam’s channel in an episode and sends Sam’s subscriber count through the roof and when Sam contacts Dovid to thank him they end up talking frequently. Dovid and Sam are single–but as I mentioned live on opposite sides of the globe. Neither of them, quite cutely, realizes how flirty they’re being as they message each other. Initially Dovid offers Sam advice on how to manage his new subscribers and ways to grow his channel but as they move beyond that and get to know each other the realization comes that perhaps there’s more there. This isn’t the first book I’ve read that relies heavily on text messages, instant messenger, email and so on. I loved how these wove into the story. There’s a good deal of, what I’ll call, regular storytelling too, coming from both points of view. Dovid and Sam have quite a lot internal dialogue about their growing predicament. Just getting time to talk on the phone is a challenge with the nine hour difference between them. It doesn’t stop them though from being ridiculously cute and challenging themselves to let this relationship go through its formative stages without being in the same physical location. Of course, the guys have to get together and that happens when Dovid and Rachel had the chance to do a European tour, which includes Ireland. As much as Dovid and Sam questioned themselves as they did the long distance thing, the jitters ratchet up as they meet. Aidan does a great job of showing the hesitancy–from Dovid wanting everything to be perfect to Sam wondering if he’s worthy of Dovid. Sam comes from a family where he was put down a lot and Dovid goes into protector mode when Sam talks about this, which is incredibly touching and sexy. For all the exploration they did via email, the time they spend together in Ireland really made me appreciate the romance that Aidan spun even more. They’d bonded so much before, they almost fall into old married couple mode with how they try to take care of each other. Dovid is particularly mindful of Sam’s asexuality and makes sure Sam isn’t doing anything he doesn’t want to do. It’s wonderful to see two such diverse characters finding their happy. Speaking if the HEA, I’d wondered how it would manifest in a book where the two characters spend probably eighty percent of the book on separate continents. I adored how Aidan brought Sam and Dovid together. I would love to see more in this universe to know how Dovid and Sam are getting on. Besides the wonderful romance, I loved the attention to detail that Aidan put into showing the work Dovid and Rachel do on their channel. From the talk of creating Patreon campaigns to managing social media and how to interact with the audience, I enjoyed it and I don’t think it’s too much for people who don’t do this kind of thing. Another excellent detail, Dovid and Rachel receive a package from a fan in Michigan–it contained Faygo Red Pop and Mackinac Island fudge, two childhood favorites that made me smile and gave me cravings! So, in case you haven’t figured it out, I totally recommend Play it Again by Aidan Wayne. I’m also looking forward to their upcoming book, Hitting the Mark, which comes out at the end of May. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish this week’s guests Hank Edwards and Deanna Wadsworth and their new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Welcome to the podcast, Hank Edwards and Deanna Wadsworth. Deanna: Hello. Jeff: Thanks for being here. Hank: Thanks for hosting us. Jeff: You guys have written a book together… Deanna: We did. Jeff: …which is super cool. April 30, which is the day after this comes out, you’re releasing the first book in the “Lacetown Murder Mysteries” called “Murder Most Lovely.” Tell us about this new series. What is the scoop? Deanna: Who wants to go first? Hank: Deanna? You go first. Deanna: Okay, I’ll go first. So like a year ago I went out to dinner with my husband, had some cocktails and at like 11:00 at night after having like wonderful conversations in my brain with myself because I think I’m clever, I messaged Hank, and I said, “Dude, we need to write a book together.” And he’s like, “We should.” And then we did. Hank: I might have had some cocktails that night too. I can’t remember. Deanna: You may have. Hank: Might have. Deanna: And it was, “Yeah, we should,” kind of moment. And we didn’t really know where it was going. Hank: We had no idea. Deanna: What’s that? Hank: We had no idea, like nothing. That was just the random start of things. “We should do a book.” We didn’t have an idea or anything. Deanna: It was a completely inane, “Dude, we should write a book together,” kind of moment. And then seriously, the next day, we had some conversations like, “What should it be? Superhero?” And then we just kind of like spitted ideas back and forth. And Hank was like, “We would write the fuck out of a rom-com.” Am I allowed to say fuck? Jeff: Yes, you are. We’ll put a little explicit logo on the episode and you can cuss as much as you want. Deanna: So he was like, “We would write the fuck out of a rom-com.” And I’m like, “We would.” And then we’re like, “What should it be?” And we just spitballed ideas back and forth. Like, I mean, literally, like there was probably like 30 or 40, like, things we shot back and forth at each other. And then Hank picked on two of them. And he’s like, “I love the idea of a mortician and a hairdresser.” Then we ran with it. Hank: Yeah, and we just ran with it. And it just started writing. I mean, we didn’t plan, like, “You take one chapter.” What we did was each of us wrote up a character bio and sent it to each other. And so I wrote up… Deanna: It was so great. Hank: You what? Deanna: It was so great, like blind dates for our character. Hank: It was. It was really fun. So you had Michael, right, and I had Jazz. Deanna: Yeah, you made Jazz. So tell us about Jazz. Hank: So Jazz is very sassy and very snarky. And he’s a talented hairstylist and he’s uprooted his life after separating from his husband, who is a best-selling novelist and mystery novelist. And so he’s moved to this small town on the coast of Lake Michigan in Michigan. And some Michigan love there, Jeff. Yes. Jeff: I love that. Hank: Yes, always. And so he’s starting over and he’s just trying to kind of like rebuild and he works at a fun little salon but he’s kind of, he’s 49 but he tells people he’s 41 and… Deanna: He tell’s people he’s 35, remember? Hank: And he tries that too. Deanna: He totally lies about his age. He says he’s 35. Hank: We had, our editor actually called us up and she was like, “Is this right?” Because he shouldn’t have been around back then. Jazz lies about his age. Deanna: He’s almost 50 but he says he’s 35. Hank: Right. So that’s how that started. And then she brought up Michael. Deanna: Yeah. Hank created Jazz, the hairdresser, which is funny because I actually legitimately am a hairdresser in real life. But when we were talking, Hank had said, “I’ve always wanted to write a hairdresser.” I’m like, “You take the hairdresser. Run with it.” And then I took the mortician, which sounded really great and exciting. And after dozens of Google search, Google decided that I obviously want to be a coroner and mortician and they send me casket ads, but yeah, whatever. So I created a…it was fun because Hank created Jazz, this sassy, almost-50 hairdresser who’s super sarcastic, he’s got long honey blonde hair and super stylish and wears eyeliner and he’s really sassy and he has a big potty mouth. Hank: Oh, yeah. Deanna: Oh, he does. And then I didn’t know who Hank was creating when we came upon this conversation. It was very much, “Hey, you pick your guy. I’ll pick my guy. We’ll see what happens. And I made Michael Fleishman who is a 42-year-old, very uptight, very socially awkward Jewish guy who runs the local funeral home and he’s also the county coroner to our fake county…is it Carver County? Hank: Carver County, yeah. Deanna: Carver County on Lake Michigan, which is sort of like in somewhere between, I don’t know… Hank: Like Saugatuck and… Deanna: Saugatuck and… Hank: Yeah, Muskegon. Deanna: Muskegon, somewhere, a fake county in between there and he’s the county coroner. He’s very uptight and super horny and has this like hilarious like sexual imagination but he’s really reserved and he is obsessed with mystery novels. And he goes to a bookstore in Lacetown, which is our fictional town on Lake Michigan, during a literary festival to meet his favorite also author, Russell Withingham, which happens to be Jazz’s husband. They’re separated but they’re not divorced yet. Hank: And that’s the meet-cute. Jeff: Wow. Hank: I know, right? Deanna: Total rom-com, meet and greet during the rain under an umbrella, cute scene. Until Jazz gets his little…I mean, he really worries Michael thinks he’s a bitchy queen and he kind of is. He’s totally the queen. Hank: He’s really fun to write. Deanna: It’s so fun. Jeff: So when you got these characters who are obviously really opposite to each other, you could just hear it in the bios, what was it like to mash them together? Hank: Oh, man. Jeff: Sparks had to have flown off the pages. Hank: Oh, yes, right away. It was really fun. The first chapter is their meet-cute. And we had…I mean, we do a lot of like editing, right? So we’ll write the first pass and we’ll talk about it. We message a lot during the day and stuff like that, talk about where we want to go with things. And then we use Google Docs to write together. Yeah, so that was a lot of fun to just see the whole creation of it and like set up that setting and understand how they were going to meet and how that was going to go and how Michael would be so taken with Jazz at first sight. It was really fun. Deanna: Totally. Like, “Oh, you’re so handsome. Why is he talking to me?” Hank: That’s really fun. Jeff: And of course you’ve got the mystery element in this too. So rom-com mystery, which trying to think, I haven’t necessarily seen that kind of combo a lot because there’s straight up romantic suspense, of course. And then there’s like cozy mystery and maybe this ekes a little towards that with the rom-com–iness. But did you know that this was going to be like something to go for? Or did you just like mash these two elements together and say, “This thing…” Deanna: We thought about doing like a film noir concept, like a 1940s film. But see, that’s the thing. Like when Hank and I started writing, we didn’t have a direction. We were very much open to anything. And it was sort of like he created Jazz, I created Michael. We knew we wanted a murder. We knew we wanted it to be like… Hank: We wanted a murder. The murder got pretty gruesome too. I was really shocked. Deanna: Yeah, we wanted some things but then as we began to write it, it began to have elements of a real murder. So like our sheriff is blustering and funny. And Michael has his kitty cat, the little Mr. Pickles. Hank: Mr. Pickles. Deanna: Mr. Pickles, the fat, black-and-white kitty, which my dog is growling at right now. Jeff: Which we should note, for the people who may not be watching the video, Deanna just held up this stuffed kitty. And you’re going to be giving these away at GRL in a few months. Deanna: Yes, we have a few couple. So like when we created the story, I guess maybe other people with their writing collaborations might be different than we were. But Hank and I were not in a competition with each other. We were not like…we just knew we were going to have fun because we like each other and we know each other personally. And we were just like, “Let’s have fun with this.” And there was no like obsessive competition with like, “I don’t like the storyline.” Or, “I like this.” It was just sort of like, “What do you want to do? Okay, that sounds fun.” And we both ran with it. And we ended up developing this city on Lake Michigan and this little town and these little side characters. Jeff: Let’s talk about the mystery side of it. Who is dead? Deanna: Oh, yes, the mystery side of it. That’s right. So I’ll talk and then I’ll let Hank talk because I’ve been blabbering too long. So we decided we wanted it to be, like, film noir idea. And then it became like a legitimate murder mystery where there is a dead body and it’s gruesome and it’s creepy and it’s sad. And there’s like some crazy shit happening. And there’s like cops that need to come in. And there’s like a real mystery. And there’s actually a couple side mysteries that are happening over the book arc of the next two novels, novel two of which we will be submitting in the morning. We would have submitted it today but I’m being a typo psycho. I am. I’m a typo psycho. Hank: She’s finding a lot of good stuff, though. I like the changes. So, yeah. So the murder actually got more gruesome than I was anticipating. We were like, “Let’s go.” “Wait, do we want to go?” “Yeah, let’s do it. Let’s do it.” So it’s…do we want to say who it is? I mean, it happens early on. So I don’t think it’s a spoiler, right? Deanna: Oh, I don’t know. Why don’t we just talk about how creepy the murder is. Hank: Okay, we’ll just leave it just like that. Deanna: Not who is murdered. Hank: Someone’s murdered and maybe their hands are missing. Deanna: Or chopped off. Jeff: Oh, wow. Hank: So, yeah, that’s kind of… Jeff: That’s more gruesome than I expect in a rom-com. Hank: I know. Jeff: I’ll say that. Deanna: Oh, wait ’till you hear about the serial killer. Wait, that was a spoiler. I didn’t say it. Hank: But in the first book… Jeff: Is that a spoiler that we’re leaving in or a spoiler that we’re taking out? Deanna: We’re leaving it in but we’re not gonna respond about it. Jeff: Fair enough. Hank: That’s right. Jeff: A little breaking news there for the podcast that we will not do follow-up questions on. You were saying, Hank, on this murder. Hank: So yeah, so it was gruesome. And then there’s the discovery. But Michael is kind of, you know, he can’t help but be a little excited about it because it’s his first murder because he’s a small town, county coroner. And the only… Deanna: He’s not only a mortician. He’s the county coroner too. Hank: Right. So it’s up to him now to, like, investigate it. He’s never had a murder like this. He’s had a murder but they knew the victim and the attacker. So this is completely new for him. And he reads murder like mystery novels, so he’s really excited about it. So he’s, like, starting to play, like, detective. And then the sheriff is kind of, you know, like all blustering and yelling at him like, “Fleishman. Dilworth.” You know, that’s Jazz’s last name, Jazz Dilworth and he like calls everybody their last name and yells at them. And they’re always a suspect, so, “Don’t leave town.” Deanna: Everyone is a suspect until Musgrave says they’re not a suspect. Hank: “Don’t leave town.” Yeah. Sheriff Musgrave. Jeff: So if I understood correctly, you kind of just created this on the fly. Hank: Yep. Deanna: Totally. Jeff: For both the romance and the mystery? Deanna: Totally. Jeff: How did that play out in like the day-to-day writing? Because I can’t even like imagine having co-written something that there wasn’t more of a plan to it. Hank [softly]: I know! Deanna: How did it go? Hank: Actually it went smoother than I expected. Deanna: It was so much fun. Hank: Yeah. And it was a lot of fun because we chatted a lot on Facebook Messenger. And we’d text and we call each other now and then. We’d have conversations, phone conversations, and we’d plan out where we wanted things to go. And then one of us would say, “Okay, I’ll do this and then you can write that.” And then we just kind of took it. And then it was really fun because like you’d go through and you’d read…you know, how you like read through what you’ve written and it’s somebody else has written something new and you’re like, “Wow, this is like a whole new story.” Like you don’t know what you’re reading, you don’t know anything of what to expect. So it was really fun. Deanna: So awesome because, like, first, I gotta say, writing with Hank Edwards has been a pleasure. Because not only is he a great writer and like stupid funny, like so funny, I can’t even tell you how many times he writes something and I’m just like…laughing. But he and I are not…we’re not competitive individuals. We’re not like jumping into this, like, “Well, this is what I want. This is what I want.” It was so easy, where it was just like we just…Hank created Jazz and then Jazz has this profile that we went with. I created Michael and we had this profile we went with. He and I created an exterior mystery that happened to them. But because he created such a good profile and I just created such a strong profile, both of us knew who Michael and who Jazz were. And then it was like, “Well, Michael wouldn’t do that,” or, “Jazz wouldn’t say that.” And we didn’t like try to, like, undermine the other person. I don’t know. I just feel really blessed. I love you. I just feel blessed to be able to write a story with someone who is so easy and so fun and our sense of humor is both very similar and darkly twisted and inappropriate, like we both knew when our editor was gonna go, “Mm-mm. No.” Hank: I told her several times, I’m like, “This is gonna get cut out and you put it in and it’s gonna get cut out. I’m telling you right now.” And she’s like, “I want to leave it in.” I’m like, “Okay, but it’s gonna get cut.” And it did. Deanna: And I’m like, “They’re not gonna let us use the C-word.” And he’s like, “Maybe they will.” No, they didn’t. But it was so much…I don’t know. It was just one of those things that were really easy because Hank is so fun to work with. It was just easy. I mean, not that writing and editing is easy. But even as we went through the process, there would be scenes…we each knew where the scene was going to go. We knew what scene was going to happen next. And if it was…because our work…he’s very typical 9:00 to 5:00 work schedule, Monday through Friday, and I am Wednesday through Saturday, noon to 8:00, those four days. So like he would do all the stuff Wednesday through Saturday and then I’d open it up on Sunday, and then I’d do all the stuff Sunday to Tuesday. And then it wasn’t like we were fixing or changing each other’s work. It was like, “Oh, that’s a great scene.” And then I would add to it. And then he would take my scene and add to it. And it was just like layering and layering cool stuff with what was already funny. So it was like I knew what I was writing on Tuesday. I wrote this whole scene. And then Hank would write the next scene. And when I would get a chance to read on Thursday, he was like, “Oh, what am I going to read? I know what’s gonna happen but how is it gonna happen?” And he is so funny. So funny. And, I mean, it was just so great writing together. Jeff: So, Hank, for you, what’s kind of your side of that story as you’re like going through and doing your part on the book on your days? Hank: So it was a lot of fun. Like Deanna said, because I’ve been writing during my lunch hours at work, so like Monday through Friday I’d have like an hour and I usually go and I hide somewhere at the building and I’ll, like, be able to focus and write. And it was really fun to go through Google Docs and be able to accept all those changes because we always do the suggestions, right, so like the track changes so we can see what each other has done. And it’s always so much fun to see. It looks like, you know, like Deanna said, it’s like, “Oh,” it’s like a little present. You know, like, “There’s something new.” And I go through. But then seeing how she did the layering, I was talking to my husband, Fred, and I was like, you know, it’s like I’m picking up such good ideas about how to layer emotion in. Deanna is awesome at doing that and like pulling out the emotions in a scene and like digging in deeper where it needs to be. You know, that’s something that I’ve always kind of like, you know, I’m always like, “Write the action. Write the action. Write the action.” Deanna: But that’s what I love about his writing because he will write action that conveys emotion, whereas I would have written a long, drawn-out emotional monologue. And somehow the two just worked so great. I think. Hank: We are a good blend together like that. So, yeah, it’s really funny and she’s funny and really darkly funny. So it’s been a lot of fun because there’s some stuff where I like write something dark and funny and then, you know, you get the comment. It’s always fun to get that comment like, “LOL. Oh, my God.” And so then like all of a sudden like further down the page, she’s added somebody I’m like, “Oh, my God, you did not just write that.” So it’s really funny. Deanna: We’re so wrong. We’re so wrong, we’re so right, Hank. Hank: Yes. Jeff: Well, I really like the organic method it sounds like you guys had. Because like my brain can’t even begin to process trying to co-write without a plan. But I’ve heard other people do that and it works out great. What, as you got the draft done, what was the revision and also, I guess, making the book seem like it had one voice? What was that like? So was it like two different people at work? Deanna: Can I respond to this? Hank: Of course. Deanna: Okay, so, Hank would send me…well, it was in Google Docs. So we would get scenes together. So I feel like the way it went before anyone else read anything or we got any feedback from editors, from beta readers, or whatever, it was like we had our strong characters decided who they were and what they were and what the mystery was. And he would write a scene and then I would get it and I’m like, “Oh, it’s a good scene. I love where it’s going. Maybe…” Okay, so like I’m not going to give a spoiler, but there’s a scene at the end of Book 1 where the murderer is caught and our two heroes are like in this epic battle fighting them, like the murderer, right? Okay. So Hank writes that scene and I’m like, “Ah,” and then I go in and I add some fighting, some struggling, and maybe a little dialogue. Hank comes back in, he adds a little more dialogue. He remembers that the gun is on the other side of the room. Whatever the detail is, we both keep adding layers. And I think it comes back to the point that we’re both so invested in our characters and we weren’t, like, competing to try to be the better person. And I think that’s a lot of it. I mean, I think you can’t co-write a book together if you’re competitive or need center of attention. Hank and I just had so much fun. It would be like, “Oh, yeah. Add that, add that.” And he’s just like “Oh, my God. We’re great. That’s great. You shot him. Oh, I didn’t expect to shoot him. Let’s do that.” Whatever it was and we kept adding these layers and it became so much fun. But in the end, when we would get a scene and it was completed, we would…each of us would go back and read through the whole manuscript and be like, “Oh, we missed that detail.” And Hank would send that to me. And I’d be like, “Oh, yeah, that’s right. I forgot about that.” And he would add it. Or I would like, even today, we’re actually like one day off submitting Book 2. We were going to submit it today but I am like typo crazy. So I sent the manuscript to my Kindle so I could find any misspellings and typos. And I was like, “Oh, my God. We have a scene where Michael and Jazz are sitting in Michael’s living room with the TV. And in Book 1, he only has a TV in his bedroom. What are we going to do?” And Hank is like, “That’s cool. Good for catching that.” And I feel like that’s kind of how we’ve been like we’ll catch something and go. “Oh, I’m glad you caught that.” Hank: Yeah. But to your point, Jeff, you said like about planning and writing off the cuff, so the first book, I think, Deanna, you can tell me if I’m wrong. But the first book was really, I mean, it wasn’t easy because writing is hard but it was easier. Book 2, it was more of a struggle I think with writing it. Deanna: Book 2 was more of a struggle. Hank: And we had a lot going on. So we have like an overarching mystery, we have another, like, contained mystery. Deanna: Yes. Hank: So we’ve talked about it and we’re like Book 3, we really need to plan it out more. We’re gonna… Like once we let this book to get out a little bit, we’re going to like start planning Book 3 and then really like… Deanna: We need a serious luncheon with some planning. Hank: Yeah, so, absolutely. Deanna: Book 1 was very organic and natural. And Book 2, I mean, you’ll probably agree, Hank, I think we fell in love with our side characters so much we got distracted with all these sides stories. Even our editor was like, “Why are you talking about that and that?” We’re like… Hank: “Because we like them.” Deanna: So we had to cut a lot of scenes and really focus back on the romance, on book 2. Jeff: DVD extras, deleted scenes. Hank: DVD extras, exactly. Jeff: But let’s talk about those side characters a little bit because there’s a whole paragraph of the blurb for Book 1 that details the side characters. Michael’s sassy assistant, Kitty, the grumpy Sheriff Musgrave, Russell’s creepy PR rep, Norbert, Michael’s grandfather who likes his Manhattans strong and his women saucy. And of course, who we’ve already met, Mr. Pickles Furryton the Third. Hank: Yes. Mm-hmm. Jeff: So did you guys split those up in the same way that you took Jazz, Hank, and Deanna took Michael? Or did these get created on the fly as you needed them? Deanna: They were on the fly. Hank: Yeah. Deanna: We just like… Hank: We just do, kind of. Yeah. Deanna: I think I came up with Mr. Pickles Furryton the Third and Hank created Sheriff Musgrave. Because I think when we were talking, Sheriff Musgrave was actually like an old man and Hank made him this whole, like, Ron Perlman kind of character. Hank: Yes. Very Ron Perlman. Deanna: He has a lot of attitude. And Kitty, I don’t know where she came from. Hank: You created Kitty. Deanna: Did I? Okay, because I imagine her. Do you watch “Blue Blood” with Tom Selleck? Jeff: I have not. Deanna: Oh, anyways. His secretary is this voluptuous like blonde chick and I pictured her. And I don’t know who created Grandpa. Hank: I think we both did. Deanna: You had Steve. Hank: Oh, yeah, the handyman. Deanna: We both made Ezra. Hank: The apprentice. Deanna: I don’t know anything about them. That’s not a spoiler at all. Jeff: That’s very impressive to just kind of create on the fly like that. Two people pantsing would make my head explode, but. Hank: It was insane. I don’t know how we managed to do it but… Jeff: I think you had fun with it all the more. Hank: …we had really good feedback from the editor. Deanna: We did have so much fun, Jeff. Hank: Yeah. Deanna: I don’t know how lucky I am. Like a year ago, I sent him a drunk text message that we should write a book together. And we have had the best year. Jeff: Had it even crossed your minds before the drunk text to do this in some, like, other random moment? Deanna: No. Hank: Never ever really even talked about it? I mean, we see each other GRL. She comes up for Ferndale Pride because she lives about an hour and a half away from me. Deanna: I’m northwest Ohio, he’s southwest Michigan, so we’ve done some pride festivals together. But in all freaking honesty, the whiskey made me do it, Jeff. I literally texted him, “Hey, full disclosure, I’ve been drinking. We should write a book together.” I do believe, Hank, that was the quote. Hank: Pretty much. Yeah. Deanna: And he was like, “We would write the fuck out of a rom-com.” And I was like, “We would.” And then we ran with it. And then that’s that. It was just, like, all fun. Jeff: And it’s interesting that you’re evolving in Book 2 and probably in Book 3 too. You had the fun moment. Now you kind of have to make everything keep tying together in the next two books. Hank: Yes. It’s all got to come together now for the third book. Yeah. Jeff: Because that’s like, yeah, when you have all that tied together stuff, because I’ve been reading a lot of romantic suspense lately where it’s like something that arcs across a trilogy or whatever, and it’s like…it’s exciting. Hank: Right. Deanna: Yeah. Book 2 is tentatively called “Murder Most Deserving,” and it was a lot harder to write than the first book. Hank: Yeah. Jeff: As fun though, I hope? Hank: Oh, yeah. Deanna: Oh yeah, just as fun, but there were moments I feel like we both checked out. And we’ve had this conversation. We know that we checked out because we had decided on a storyline for Michael and Jazz. And then we were like, “This doesn’t feel right.” Because it’s not your book, it also belongs to someone else, you don’t just say, “Oh, that storyline can’t happen,” because two of you decided together so you keep going with it. And then there’s moments where we had to talk and we’re like…where I was like, “I don’t like this.” And he’s like, “Yeah, I don’t like it either.” And I thought I said I didn’t like it. I’m like, “Maybe you said you didn’t like it. But I didn’t really expect you didn’t like it and I don’t know why we didn’t like it. And I don’t even know why we’re doing it.” And it was like we had…I mean, there was like, there was a couple of moments like that on the story. And there was also like we said in the beginning, we love our side characters too much. And we gave them a lot of screen time they did not deserve, even though we love them. So we had to distract and take a lot of stuff out. Not that we wanted to take it out but it was like why is this thing here? No one cares… Hank: Right. Deanna: …except us. So it was a little different. Like we created this wonderful world and in Book 2 we kind of just went crazy. We, like, went crazy with the Cheez Whiz. It’s like, “I love Sheriff Musgrave. I love Missy.” And we just wrote all these scenes and we’re like… And part of that I will say is my fault because I sent a lot of scenes to Hank before we even plotted the book. I was like, “I wrote this funny scene I’m going to send you.” And he’s like, “I love it.” And we wrote it. Hank: And I was like opening emails from Oprah. “And you get a storyline, and you get a storyline.” Deanna: Totally. Jeff: Maybe these could become short stories for these characters if you can’t get them into the book. Hank: That’s great. Jeff: So take a moment to brag on each other. And outside of working on this book, what do you like about each other’s work? Hank: I’ll go. Jeff: Hank first. Hank: All right. I love Deanna’s depth of characters. So her books, I think the first one I read of yours was “The Legend of Sleepy Hollow.” And I was like, “Oh, Ichabod. Oh, you naughty boy.” But then I can’t remember in what order then I read them but like “Easy Ryder,” I love that book. That is an awesome book. And I love the time period and I love the characters and I just love all of it and the discovery. That’s a road trip, another…you love the road trip books. Deanna: Apparently. Hank: Apparently. And then “Wrecked” is awesome. It’s really good. But she has a way of just like, you know, pulling up those emotions and really getting into the romance of it and doing an awesome job with it and having the characters. And then the conflict is organic, it’s not, like, fabricated. And it all blends together. She’s got a really good sense of story. Jeff: Nice. Deanna: That’s so sweet. I feel like, Hank, your dialogue sells your story. You could write a whole book on just dialogue with nothing else and people would buy it and laugh. You’re hilarious and your dialogue is great. And I feel like our styles mesh well because I do write more… I like to write a lot of the internal monologue and the emotion. But I’ll tell you an example, and this is a semi-spoiler in Book 2. But this is what I love about Hank’s writing. Okay. I’m not gonna tell too much of the story but there is a scene where something really shocking happens for our character, Jazz, the hairdresser. And the scene is in Jazz’s point of view. You’ll know what I’m talking about in a second. So the scene is in Jazz’s point of view and then Michael, our mortician, bursts through the door. And everyone is like, “How did you get here?” And he’s like, “I ran here.” And that sounds like simplistic but the emotional intensity of why Michael would run five blocks to the salon where Jazz works on a mere phone call just conveys so much intensity with three words, “I ran here.” And that’s what I love about Hank’s writing. I mean, I write the long emotional, internal monologue. And Hank writes that same intense emotional monologue in three words, “I ran here.” And I think, I mean, I’ve always…that’s what I love about his books. But I feel like those two things complement each other in our writing. Like I like to write the long drawn out emotional and he writes that same scene in three words, “I ran here.” And that’s why I love writing with him. Jeff: Cool. They’re hearting each other for those people not watching the video right now. Jeff: So you mentioned three towns…three towns, no, three books in the “Lacetown” series are planned. Do you foresee life in the universe beyond those three since you’re having such a good time? Deanna: Yeah. Hank: We talked about it. We’ve discussed it, yeah. We’ve got the trilogy planned and then we’ll see what happens with it. Deanna: We have at least two in our head. Jeff: That’s cool. Deanna: Beyond the three. Jeff: Now what about separately? What’s coming up next outside of the “Lacetown” series for you both? Hank: You have something coming up soon, Deanna. Deanna: Well, I have one thing coming up for sure and hopefully two. I also write young adult fiction just like Hank does under his…is it RG or RD? Hank: R.G. Deanna: R.G. Thomas. Hank has a young adult series under RG Thomas. And I have a young adult series, K.D. Worth, which is very different from my Deanna Wadsworth writing. It’s young adults/new adults because my characters are 19 and there are some, I don’t know, level-three sexy moments. So you can’t really…like you know people get funny about young adult that has sexy stuff in it. There’s a strong spiritual element with the main character who was trying to kill himself because of his family sending him to like one of those creepy pray-the-gay away camps. And the moment he kills himself he’s saved by a young teenage Grim Reaper, who decides that he wants to give him a second chance in life. And there’s a sassy foul-mouthed, because no one understands why Deanna would write a character like that, a sassy foul-mouthed angel who helps these boys on their journey. And that story is called “The Grim Life.” And Book 3, the final series, the final saga in that trilogy “The Lost Souls” is coming out this fall. And I’m really, really excited about that. I mean, a lot of M/M or gay romance, whatever you want to call it, authors know that young adult isn’t where the sales and money are at, sadly, but this is like a really intense…I don’t want to say pet project because that trivializes it, but it’s really a series that means more to me than almost anything I’ve ever written. Hank: Yeah. You’ve been working on these for what? Like two years now? Deanna: Yeah, four. It took me two years to write Book 3 because I just emotionally invested in it. There’s a lot of death and questioning of what goes on on the other side and where God sees your soul and all these like intensely hard questions. And to make things harder on myself, I put a school shooting in Book 3 because why not? Hank: No, why? Deanna: It’s so emotionally intense that you can’t write it. So that comes out this fall. But I’m hoping my second book in my Pride of the Caribbean Cruise series comes out which is a merman. Hank: Nice. Deanna: A merman… Hank: On a cruise. Deanna: …on a Caribbean cruise. It’s like I like to be intense or I like to be funny. I can’t be… Hank: There’s no in between, right. Jeff: Either end of the spectrum. Hank: That’s right. Deanna: That’s what I do. So that’s what’s coming out for me. Jeff: Cool. Hank: I will be working on the final book of the “Critter Catcher” series, final book for now. It’s tentatively titled “Dread of Night.” So and I’ve got about six chapters written. I’m working on a big pivotal scene also, so I need to just like…now that Book 2 has been sent off for consideration I can like, you know, kind of focus on that because I’m really bad at like jumping between projects too. Like my mind gets stuck in the other characters because while I’m working on this other I’m like, “But wait, what about…?” So, yeah. Jeff: Cool. All right. What is the… Hank: There’s other stuff to work on too but that’s the big thing coming up. Deanna: I love the “Critter Catcher” books. They’re so good. I manipulated Hank into giving me the last book when I was sick last summer. I was like, “Shouldn’t you send it to me? I know that you’re going to submit it for publishing in a month, but I’m really sick.” Hank: “I need to beta it. I’m sick.” Yeah. Deanna: Yes. I did do that. Jeff: And it worked too, right? Deanna: It worked. Hank: I did. I sent it. I was good. Deanna: And it was worth it. Jeff: So what’s the best way for readers to keep up with you guys online? Let’s start with Hank. Hank: I have a website. It’s hankedwardsbooks.com. You can also find my young adult fiction at townofsuperstition.com. And I do have those books listed on my Hank Edwards’ website just to make it easier. And then I’m on Facebook. I have a Facebook page. It’s facebook.com/hankedwardsbooks. And I really don’t use…Twitter confuses me. I get really…it’s just this noise. It’s like people yelling at each other. And so I have a Twitter account but I’m not out there much. But I am on Instagram. I usually post pictures of my cats. You know, and that’s @hankedwardsbooks as well. Jeff: Cool. And Deanna? Deanna: I’m on Facebook, deannawadsworthauthor. And Instagram, I go by @deannawads. I don’t know why I didn’t finish my last name but I don’t know. Everybody called my grandpa Wadsy. So I should have done Deanna Wadsy but I screwed that up. But I’m on those two. A little on Twitter and a little on Pinterest, all under Deanna Wadsworth. Mostly my most activity is on Instagram or my website, deannawadsworth.com. And that’s it. And you should totally read Hank’s R.G. Thomas books. It’s like Harry Potter but gay with, like, dragons. And little garden gnomes. I fricking love those books. You better write another one after we write our book. After we write our book. You’ve got to. Hank: Got it. Jeff: You’ve got your marching orders now, Hank. Hank: I do. I get them a lot. Deanna: He doesn’t have a wife, but… Hank: It’s all right. Deanna: …I’ll jump in that role. Hank: She’s my work wife. Jeff: All right. Well, this has been a blast. We will definitely link up to everything in the show notes that we’ve talked about here. And we wish you the best of success on the “Lacetown Murder Mysteries.” Hank: Thanks very much, Jeff. It’s been fun. Deanna: Thank you, Jeff.

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 my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: 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%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, 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! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)

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 my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes.  Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: 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. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, 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 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)

Shownotes 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 tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department. Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement. Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches. Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all. Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine. Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies. Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%. Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia. Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on…. Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain. Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that.. Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes! Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES. Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients. Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list. For a visual reference, see Table 3 in the print issue. Nachi: And patients with neurologic deficits or severe sudden-onset headaches, should be transported immediately to the nearest available stroke center. Tylenol should be offered for pain management. Avoid opioids and nsaids. Jeff: Upon arrival to the emergency department, history and physical should include your standard vitals, testing neurologic function, cranial nerve testing, head and neck exam, as well as a fundoscopic exam. As was the case for your pre-hospital colleagues, you should also assess for red flag signs for life-threatening headaches. Check out tables 2, 3, and 4 for more details here. Nachi: With respect to Vital Signs, in the setting of an acute headache, severe hypertension should prompt a search for signs of end-organ damage such as hypertensive encephalopathy, intracranial Hemorrhage, PRES, and preeclampsia in pregnant women. Additionally, fever, and especially fever and neck stiffness, should raise concern for CNS infection. Jeff: For your neurologic examination, make sure to include assessments of motor strength, coordination, reflexes, sensory function, and gait. Don't forget that lesions involving the anterior circulation, such as dysarthria, cognitive impairment, and Horner syndrome may be indicative of a carotid artery dissection, whereas dizziness, vision changes, and limb weakness may be due to a vertebral Artery Dissection. Nachi: And for cranial nerve testing - pay particular attention to cranial nerves 2, 3 and 6. For cranial nerve 2 - look out for an afferent pupillary defect, or a marcus-gunn pupil, which is seen in optic neuritis, giant cell artertitis, and central retinal artery occlusion. For CN3, oculomotor nerve palsies raise concern for a posterior communicating aneurysm and SAH. And lastly, CN6 palsies, which often presents with diplopia on lateral gaze , are often seen with intracranial idiopathic hypertension and cerebral venous thrombosis, in addition to impaired visual acuity, visual field defects, and tunnel vision. Jeff: For the head and neck exam, remember that a partial horner syndrome, with miosis and ptosis without anhidrosis, may be indicative of a cervical artery dissection. Unfortunately, if the patient presents acutely, their only complaint may be pain, as the neurologic sequelae may take days to develop. Nachi: Additionally, with respect to the head and neck exam, evaluate the patient for tenderness and beading along the temporal artery. Jeff: One review noted that temporal artery beading actually had the highest likelihood ratio for GCA, 4.6, whereas temporal artery tenderness only had a LR of 2.6 Nachi: And the last physical exam maneuver you should ideally perform is a fundoscopic exam for papilledema, which is often seen in IIH, malignant hypertension, and CVT. Jeff: Perfect so that rounds out the physical, next we have diagnostic studies. Most importantly, routine lab testing is typically of low utility in aiding in the diagnosis of headache. Nachi: Even ESR and CRP in the setting of possible giant cell arteritis have poor sensitivity and specificity to diagnose it. So even if the ESR and CRP are negative, if the suspicion for GCA is high enough, it should be treated and you should get a biopsy. Jeff: Do consider adding on a venous or arterial carboxyhemoglobin in the right clinical scenario, as CO poisoning represents an important cause of headache you wouldn’t want to miss. This is especially important at this time of year when heating systems are working overtime here in the states. Nachi: And hopefully you have a co-oximeter, so you can even check this non-invasively. Jeff: Interestingly, there may be a unique role for a d-dimer here as well. Several small studies have used the d-dimer to risk stratify patients with possible CVT. In one study a d-dimer level < 500 mcg/L had a 97% sensitivity and a negative predictive value of 99% - not bad! Nachi: Pretty impressive performance characteristics. I think that about wraps up lab work. Let’s talk radiology. Jeff: Though low yield, CT utilization is estimated at 2.5-10% of non-traumatic headaches. A non-con CT should be reserved for those with suspicion for an intracranial hemorrhage, while a contrast CT would be required in those in whom there is concern for an infectious process or space occupying lesion. Nachi: CT angio or MRI should be used in cases of possible cervical artery dissection. MRI also is the neuroimaging of choice for PRES, which is more sensitive for cerebral edema than CT. Jeff: Similarly, MRV is recommended in those with a concerning story for CVT. Nachi: To help guide your emergent neuroimaging utilization, ACEP suggests imaging in those with headache and an abnormal finding on neuro exam, those with new and sudden-onset severe headache, HIV positive patients with new headache, and those over 50 with a new headache. Jeff: With that in mind, let’s dive a bit deeper into the use of CT for SAH, a topic which doesn’t get a ding sound, but is certainly critically important. Recent literature have found that a CT within 6 hours of symptom onset has a sensitivity and specificity and negative predictive value of 100%. In addition, one 2016 study demonstrated a LR of 0.01 in those with a negative HCT within 6 hours. These are really important results because that means SAH is essentially ruled out with a negative study. Nachi: Unfortunately, the 2008 ACEP guideline and 2012 AHA guidelines still recommend a lumbar puncture in those being worked up for SAH. Luckily the ACEP guideline is currently being revised so your decision to forego the LP with a negative HCT in the first 6 hours will likely also be backed by ACEP in the near future. Jeff: That’s a nice transition into our next test - the LP. Since LP carries a risk of herniation, in those with signs of increased ICP, make sure to get appropriate neuroimaging before attempting the puncture. In those without signs of increased ICP, no imaging is necessary. Nachi: While the position in which the LP is performed doesn’t matter as much when ruling out infection or SAH, in those with suspected IIH, make sure to obtain an opening pressure with the patient lying in the lateral decubitus position. An opening pressure of greater than 25 is often seen in IIH. Jeff: And the LP in the setting of IIH is not only diagnostic but also potentially therapeutic, as the removal of 1 ml of CSF can lower the pressure by 1 cm of H20 and potentially relieve the patient’s symptoms. Nachi: Always rewarding to diagnose and treat simultaneously... Jeff: Absolutely. But back to the LP for SAH for a second or two. When evaluating for a subarachnoid hemorrhage, you’ll often note an opening pressure of greater than 20 with persistent RBC in all tubes. Nachi: While there are no RBC cutoffs, one study found no patients with a SAH with less than 100 RBC in the final tube. In contrast, greater than 10,000 RBC increased the odds by a factor of 6. In addition, one 2015 study found that patients without xanthrochromia and less than 2000 RBC were effectively ruled out of having a SAH with a combined sensitivity of 100% Jeff: Lots of 100% sensitivities and specificities being thrown around today, which is definitely not the norm. No complaints here, I’ll take it. Anyway, the last test to discuss is our good friend the ultrasound, specifically the ocular ultrasound. Nachi: Examining the optic nerve sheath 3 mm posterior to the globe, an optic nerve sheath diameter of 5 mm or greater is predictive of an ICP greater than 20. Jeff: Keep in mind that this may expedite the work up, though a normal diameter does not rule out increased ICP, so a head CT may still be indicated. Nachi: Alright, so we’ve talked a lot about testing, both lab and imaging, and we’ve mentioned a bunch of pathologies, but let’s spend a few minutes going over the specifics of each. Jeff: Let’s start with SAH. SAH account for 1% of all headache visits to the ED. Most nontraumatic SAH are caused by aneurysm rupture. A missed diagnosis of SAH can have a case-fatality rate as high as 50% Nachi: Although 75% of SAH patients report an abrupt onset, objective neck stiffness has the highest likelihood ratio of 6.6. Other important features include LOC, neurologic deficit, subjective neck stiffness, photophobia, and onset during exertion or intercourse. Jeff: Additionally, approximately 20% of patients with a SAH have warning signs of a sentinel bleed including headaches, cranial nerve palsies, neck pain, or nausea and vomiting. Nachi: In order to aid you in diagnosing a SAH, you should consider the ottawa SAH Rule which has a 100% sensitivity and a 15% specificity. To use this rule you must be between 15 and 40 with a GCS of 15 and present with a headache with maximal intensity within 1 hour of onset. If you meet those inclusion criteria, and you have no neurologic deficits, no neck pain or stiffness, no witnessed LOC, no onset during exertion, no limitation of neck flexion, and no thunderclap onset, you can essentially rule out a SAH. Jeff: While the ottawa SAH rule has been prospectively validated, know that this study has been challenged for its interobserver variability, but in any case it still provides helpful red flags to consider. If your patient is found to have a SAH, a CT angiogram and neurosurgical consultation should be considered immediately. Nachi: In addition to monitoring ABCs, early care involves the administration of analgesics and anti-emetics. Also consider elevating the head of the bed to 30 deg, which may also improve venous drainage and decrease ICP. Jeff: In terms of BP management, guidelines from the american stroke association recommend targeting a SBP of 160 with a titratable agent like nicardipine or clevidipine. Nachi: In addition, nimodipine, 60 mg q4h, should be given to those with aneurysmal SAH to improve outcomes. Jeff: and any role for anti-epileptics? Nachi: That’s controversial and the authors state it may be considered in the immediate post-hemorrhagic period and should be limited to a 3-7 day course with longer courses required in special populations. Jeff: The next pathology to discuss is cervical artery dissections, which account for 2% of all strokes and nearly 20% of strokes in those 50 and under. cervical artery dissections are most commonly due to trauma, but can occur spontaneously. Nachi: Risk factors include Ehlers-Danlos syndrome, osteogenesis imperfecta, and Marfan syndrome. Jeff: Regardless of the etiology, the management of cervical artery dissections is primarily medical with IV heparin followed by warfarin or a direct oral anticoagulant in those with extracranial dissections, and antiplatelet therapy like aspirin or clopidogrel in those with intracranial dissections. Nachi: Thanks to the CADISP study, we know there is no difference in mortality or neurologic outcome when choosing between antiplatelet therapy and anticoagulation. Jeff: Next we have cerebral venous thrombosis. This typically presents with a gradual onset headache. Though it can happen to anybody, cerebral venous thrombosis typically results from thrombotic disease. Nachi: Important risk factors include oral contraceptive use, pregnancy and postpartum states, Factor V Leiden deficiency, and lupus. Jeff: Treatment for CVT is controversial due to a high risk of hemorrhage and hemorrhagic transformation. According to the best available evidence, anticoagulation is the standard therapy with full dose anticoagulation of low-molecular weight heparin or heparin as a bridge to warfarin. Nachi: Yeah, it’s really a tough spot to be in as one third end up having some form of hemorrhage too…. Jeff: Perhaps yet another good place for shared decision making? Nachi: Honestly, it’s a good thought, but anticoagulation is the guideline recommendation, so I think that is likely the best route in this case. Jeff: Great point. Next we have idiopathic intracranial hypertension. This is typically associated with obese women of childbearing age. It may also be due to hypervitaminosis A from excessive dietary intake and even drugs like the retinoids used in treating dermatologic conditions and cancers. Nachi: idiopathic intracranial hypertension can be diagnosed by the modified dandy criteria which are found in table 8 on page 11. Let’s just run through the criteria. Jeff: The modified Dandy criteria for idiopathic intracranial hypertension include: signs and symptoms of increased ICP, no other neurologic abnormalities or altered level of consciousness, ICP > 20 on LP with normal CSF composition, neuroimaging without another etiology for intracranial hypertension, and lastly no other identified cause of intracranial hypertension. Nachi: And as we mentioned a few minutes ago, an LP can be both diagnostic and therapeutic, though the relief is likely temporary Jeff: For more permanent treatment, weight loss is the key. Acetazolamide, 250 mg to 500 BID is the first line pharmacotherapy. Combined with weight loss, acetazolamide and a low sodium diet has been shown to improve visual field function. Nachi: And if this fails, topiramate, furosemide, and in the worst case surgical options like CSF shunting, venous sinus stenting, and optic sheath fenestration are all options. Jeff: I imagine taking a diuretic for a headache could be a real hindrance on quality of life, though I suppose it’s better than risking vision loss or having a significant neurosurgery. Nachi: Agreed. Next we have giant cell arteritis. GCA is rare, with a prevalence of

  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...

  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!  

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 back with our old routine – no special guests. Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes. Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury. Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance. Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface. Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors. Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns. Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries. Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure. Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs. Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries. Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation. Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury. Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns. Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries. Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury. Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion. Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high. Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating. Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described. Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live. Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself. Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful. Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high. Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries. Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different. Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines. Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed. Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring. Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h. Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up. Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey. Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect. Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome. Jeff: So that wraps up the physical, let’s move onto diagnostic studies. Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries. Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis. Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate. Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region. Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment. Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center. Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally. Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h. Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed. Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about thermal burns in Epsiode 13 also, so go back and listen there for more... Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach. Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids. Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding. Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding. Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult. Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock. Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed. Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser. Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that. Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls. Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium Nachi: Basically, [DING SOUND} those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients. Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways. Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect. Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention. Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases. Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases. Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike! Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer. Nachi: Yinzer? Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates. Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis. Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval. Nachi: Let’s touch upon any other details regarding disposition. Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions. Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient. Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required. Nachi: That wraps up Episode 22, but let’s go over some key points and clinical pearls. During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma. Thermal injury can lead to muscle breakdown, rhabdomyolysis, myonecrosis, edema, compartment syndrome, osteonecrosis, and even periosteal burns. Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries. Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury. Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury. High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours. Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam. For severe injuries, target a urine output rate of 1-1.5 mL/kg/hr. All patients with serious electrical injuries require serial exams to evaluate for vascular compromise and compartment syndrome. Address pain with analgesia. Larger than expected doses may be needed. Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required. For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding. Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock. Tympanic membrane rupture is a commonly noted blast injury after a lightning strike. Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your tyipcal cardiac arrest patient as the patient population is typically younger and without significant comorbidities. When determining destination, trauma centers take priority over burn centers if those sites are different. So that wraps up episode 22 - managing electrical injury in the emergency department. 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 credits. 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. And the address for this month’s credit is ebmedicine.net/E1118, 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!

Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. 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 and we'll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month's topic is one that Jeff has significant personal experience with from his college days. We're reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month's issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We're going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you're listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you're not driving while listening, be sure to jot down these answers and get your CME credit when we're going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let's get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found...

Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. 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 and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And   -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1).  More on TRPV1 later... Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes. Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops. Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse. Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately. Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue. Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids. Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases. Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist. Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few. Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations. Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3 times higher risk of stroke or TIA. Nachi: And there is moderate quality evidence that this link may be dose-dependent. Larger amounts of cannabis use lead to cerebral vasospasm and a reduction in cerebral blood flow. Jeff: In terms of psychiatric effects, several low-to-moderate quality studies have shown statistically significant associations between psychosis and self-reported cannabis use. Some association between high potency cannabis or synthetic cannabinoid use with new-onset psychosis or relapse in previous psychiatric disorders has also been found. Lastly, there is weak data supporting a correlation between cannabis use and depression. Nachi: From a cardiovascular standpoint, cannabis use is associated with increased resting heart rate, hypertension, and decreases in the anginal threshold for patients with chronic stable angina. A 2001 study described an augmented risk of myocardial infarction within the first hour of cannabis use and found an almost 5-fold increase in those who reported smoking cannabis at least weekly when compared to those who smoked monthly or less. Jeff: Dysrhythmias, qt prolongation, av blocks, myocarditis, and sudden death have all been reported with cannabinoids. Nachi: In terms of pulmonary effects, these are not really related to cannabis use directly, but rather the smoke inhalation and combustion materials of synthetic cannabinoids. Effects from chronic use can be seen. Jeff: Renally speaking, acute kidney injury and rhabdomyolysis are associated with synthetic cannabinoids and have been observed in several case reports. The rhabdo is believed to be due, in part, to associated seizures, muscle tremors, and agitation. Nachi: Among metabolic abnormalities, patients can present with hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. Jeff: Orally and dentally, dry mouth is the most common finding in acute cannabis toxicity. Chronic use has also been linked to severe periodontitis. Nachi: And ophthalmologically, there is, of course, the commonly seen conjunctival injection. Cannabis has also been found to decrease intraocular pressure when used topically -- and of note, there have also been rare reports of acute angle closure glaucoma and central retinal vein occlusion. Jeff: While talking about clinical findings and systemic effects of cannabis use, we certainly need to go over cannabinoid hyperemesis syndrome (or CHS), which is -- quite simply put -- associated with frequent visits to the ED in chronic users. It presents with nausea, vomiting, and abdominal pain. Nachi: CHS is commonly misdiagnosed as cyclical vomiting syndrome. After the legalization of marijuana in Colorado, it was reported that nearly twice as many patients had presented for what was thought to be cyclical vomiting syndrome. And ironically, though cannabis has been used as an anti-emetic, chronic use can cause the opposite reaction, leading to CHS, which is typically refractory to traditional anti-emetics. Jeff: And the etiology of CHS is not well understood. Similarly, the exact criteria for CHS are poorly defined. It presents as a recurrent and relapsing disorder that can be divided into 3 phases: prodromal, hyperemetic, and recovery. Nachi: In the prodromal phase, patients complain of early morning nausea without vomiting, and they can have mild abdominal discomfort. This can last from months to years. In the hyperemetic phase, patients complain of severe, unremitting abdominal pain with repeated episodes of vomiting and retching. This is often associated with an inability to tolerate po. Jeff: The hyperemetic phase lasts 24-48 hours and can lead to dehydration, electrolyte abnormalities, and weight loss. Patients may learn to relieve symptoms by compulsively bathing in hot water. Nachi: Resolution of symptoms is seen when the patient stops using cannabis. This is during the recovery phase, which can last from days to months. But this can be short-lived if the patients begin using cannabis again. Jeff: On that note, we should also touch on cannabis withdrawal. Termination of heavy and habitual use can lead to withdrawal syndromes within 48 hours. Symptoms here include irritability, anxiety, restlessness, sleep difficulty, seizures, and aggression. Medications that can be helpful include benzodiazepines, neuroleptic agents, and quetiapine in refractory cases. Nachi: Moving on to the next sections in the article, let’s talk about differential diagnosis and prehospital care. The differential for acute cannabinoid intoxication, as you might suspect, is broad, and it includes some life-threatening processes. We won’t list them here, but be sure to think broadly before deciding on cannabis as the cause of your patient’s symptoms. Jeff: For the prehospital providers -- care here is mainly supportive. Provide airway protection as needed - gather information from the patient’s environment, looking for empty pill bottles or another empty packaging. Nachi: Let’s move on to care once in the ED. All patients who are in distress and suspected of drug ingestion should be disrobed completely and placed on a cardiac monitor. Fully assess for trauma and place an IV in the patient. Search the patient’s clothing for drugs and paraphernalia, which may help in making the diagnosis. Jeff: When getting a complete history from the patient, it may also be worthwhile to talk with any persons accompanying the patient to the ER for more information. In your history, be sure to ask about a pattern of use and possible co-ingestions. Nachi: When considering cannabis hyperemesis syndrome, a detailed history and physical exam are crucial for making the diagnosis. To differentiate between other etiologies of abdominal pain and vomiting, be sure to ask about the use of hot baths for relief, resolution of symptoms after stopping cannabis use, and the predominance of symptoms in the morning hours. Jeff: On physical exam, for cannabis intoxication, there isn’t a particular toxidrome to look for. Monitor vital signs closely, looking out for alterations in blood pressure and heart rate. A complete neurologic and mental status examination will be the key here. Nachi: Decisions for lab testing should be dependent on the patient’s presentation. Possible tests include CBC, BMP, LFT’s, lipase, cpk, ckmb, troponin, urinalysis, urine drug screening, serum tox screens (for alcohol, aspirin, and acetaminophen), and any other drug levels for medications that the patient is taking for medicinal purposes, like phenytoin or lithium levels. Jeff: One study supported point of care urine drug testing in the ED. However, know that acute cannabis intoxication can be difficult in the chronic user, as delta-9-THC will be present in urine for up to 24 days. Testing for synthetically derived cannabinoids is difficult due to changes in synthetic compounds. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings. These include ibuprofen, pantoprazole, efavirenz, and lamotrigine. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. You’re looking for signs of ischemia, arrhythmia, and interval abnormalities. Serum and urine tox tests are not particularly helpful in the acute chest pain patient who is using synthetic marijuana. Nachi: Not surprisingly, there are no specific diagnostic imaging modalities to help diagnose cannabis or synthetic cannabinoid intoxication. But imaging may help with assessing other disease states on a patient’s differential, so stay mindful of that. Jeff: Now that we’ve talked about history, physical exam, and useful testing modalities, let’s talk about treatment for cannabis and synthetic cannabinoid toxicity… therapy is primarily focused on supportive care. Most ED visits only require a short stay. Nachi: That’s right, there are no antidotes to give for treatment here. Be sure to look for and treat dehydration, acute renal failure, and rhabdo though. In severe cases of neuropsychotropic effect, give benzodiazepines, like lorazepam, to help with control. Jeff: For GI effects, first-line treatment is traditional anti-emetics like ondansetron or metoclopramide. Recent literature and case reports have shown significant improvement with butyrophenones like haloperidol as a second-line treatment. Nachi: While talking about treating the gastrointestinal effects of cannabis toxicity, let’s also discuss methods to control cannabinoid hyperemesis syndrome. The mainstays for treatment here are actually supportive therapy and cessation of cannabis use. Jeff: And can you tell us more about why these patients crave hot showers and improve after? Is there a pathophysiology or mechanism to know about there? Nachi: There is a well-studied theory here and it relates to the TRPV1 receptor that we talked about earlier. Temperatures in excess of 109 degrees Fahrenheit, acidic conditions, and compounds found in certain foods and plants (like cannabis) activate this receptor. It’s believed that intermittent and repetitive exposure to agonists of the TRPV1 receptor leads to a persistent state of nausea and vomiting. Desensitization of the receptor happens after repeated stimulation, and repetitive topical capsaicin or hot water is believed to function as an exogenous agonist. Jeff: In any case of repetitive emesis, be sure to consider electrolyte replacement if needed. In many cases, hydration or repletion will need to happen through an IV. Proton pump inhibitors can also help in some cases where GI symptoms are a dominating complaint of the patient. Nachi: Recent literature supporting the use of haloperidol for nausea and vomiting has found that symptoms improve approx 1hr after administration. This can decrease the need for observation or admission. Jeff: Haloperidol works via dopamine 2 receptor antagonism. D2 receptors are found in high concentrations throughout the nervous system and bind with high affinity to haloperidol. The suggested starting dose is 2.5mg IV with a repeat dose of 5mg IV if needed. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019. Nachi: Capsaicin has similarly shown promise in cannabis hyperemesis syndrome through the TRPV1 receptor as we discussed already. Currently, there are no dosing recommendations or application instructions for capsaicin. There is some evidence supporting relief within 30 to 45 minutes, and capsaicin can be applied topically to any nonmucosal surface like the abdomen, chest, or back. Jeff: So to recap -for cannabis hyperemesis syndrome, treat with anti-emetics, PPI’s, electrolyte repletion, and IV hydration as needed. As a second line treatment, consider haloperidol and topical capsaicin applied to the chest, abdomen, or back. Nachi: Let’s talk about some special populations next -- starting with Pediatrics. According to data from 2012, of the 130 million people reporting illicit drug use within their lifetime, 25% were children between 12 and 17 years of age. Jeff: And according to the national poison data system, states with marijuana use laws have seen a 30% increase in calls related to marijuana use by children. From 2010 to 2011, the number of ED visits by children aged 12 to 17 years old due to synthetic cannabinoid use also has doubled. Nachi: Many children and adults believe that synthetic cannabinoids don’t pose serious health risks, as these are not illegal to purchase. And this class of drugs is particularly attractive to adolescents since it will not readily test positive on urine drug tests. All of this is very concerning for emergency clinicians. Jeff: There have been several recent reports of myocarditis in association with marijuana use. One case resulted in death due to myocyte necrosis after an unknown amount of edible marijuana was consumed by a toddler. Nachi: Horrific! Jeff: And the exact mechanism through which the myocardial necrosis happens isn’t known. Nachi: For all children and adolescents who present to the ED with alteration in mental status, psychosis, or chest pain -- be sure to screen for cannabis or synthetic cannabinoid use.  There are case reports in the pediatric literature of STEMIs seen in patients without pre-existing cardiac disease or risk factors. Jeff: Keep in mind that urine drug screens can be falsely positive from certain proton pump inhibitors, so if possible, assess a urine drug screen prior to starting a PPI in these patients. Nachi: Moving on to our next special population… pregnant women. Know that it can be difficult to the differential between hyperemesis gravidarum and cannabis hyperemesis syndrome in pregnant patients. Ask specific questions regarding marijuana use before and during the pregnancy. Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Nachi: Let’s move on to the final major section of the article, which is on the legal status of cannabis and cannabinoids. Much of the controversy surrounding cannabis for medicinal use relates to the absence of quality evidence. More research is needed to evaluate potential public health risks posed by variations in quality and potency, potential impact to our healthcare system, and ability to legislate for synthetic cannabinoids. Jeff: Though marijuana and all whole-plant derivatives are schedules I controlled substances, there are a few cannabinoid-based drugs approved by the FDA for medicinal purposes -- with lower schedule designations. Dronabinol is a schedule III drug derived synthetically from delta-9-THC. It’s used in chemotherapy-induced nausea/vomiting, as well as anorexia and weight loss from AIDS/cancer. Nachi: Nabilone, a schedule II synthetic variant of THC, has been approved in the treatment of aids-related anorexia and chemotherapy-induced nausea also. Jeff: Nabiximols, a plant-derived cannabinoid, has been approved in Europe and Canada for multiple sclerosis induced spasticity and cancer-related pain. Nabiximols are not yet approved in the US. Nachi: And lastly, we should mention cannabidiol, which is a schedule I controlled substance approved for treatment of seizures with 2 rare diseases -- Lennox-gastaut syndrome and dravet syndrome. Compared with placebo alone cannabidiol and other medications have shown efficacy in lowering the rate of seizures for these diseases. Jeff:  Lots of interesting stuff to look out for there in cannabinoid-related medications. Alright, on to disposition - Nachi: Most patients who present with uncomplicated acute cannabis or synthetic cannabinoid intoxication can be observed until clinically sober. Discharge home should be in the care of a sober family member or friend. Make sure that the patient knows not to operate vehicles or heavy machinery under the influence of drugs. Counsel them on drug abuse also. Jeff:   In more rare situations, patients will require admission. Consider this particularly for patients who have end-organ damage, rhabdomyolysis, acute renal failure -- evidence of cardiovascular, cerebrovascular, or ophthalmologic insults -- intractable vomiting, or acute psychosis. Nachi: And for cannabinoid hyperemesis syndrome, patients may require admission for IV hydration and electrolyte correction. Once the patient is tolerating PO and lab derangements have been corrected, they can be discharged. Jeff: Let’s wrap up the episode with key points and clinical pearls… N: Marijuana is the most commonly used illicit substance in the US. States that have legalized marijuana for medical and recreational purposes are showing increased rates of marijuana abuse and dependence. J: When concerned with drug intoxication, search your patient’s clothing for drugs and paraphernalia on arrival. N: The neuropsychiatric and addictive properties of cannabis are due primarily to delta-9-THC. J: Synthetic cannabinoids have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designations as well as routine urine drug screening tests. N: Manufacturers of synthetic cannabinoids sometimes use solvents and other contaminants, which have caused clusters of toxic ingestions and death. J: The shortest duration to peak plasma levels of delta-9-THC is through the inhalational route. Effects can be seen within 3 minutes. N: Cannabis users who smoke at least once weekly can have a 3.3 times higher risk of stroke or TIA. J: The risk of myocardial infarction is increased within the first hour of use, and there is an almost 5-fold increase for individuals who smoke at least once per week. N: Acute kidney injury and rhabdomyolysis have been noted with synthetic cannabinoid use in several case reports. J: Cannabis intoxication is associated with many metabolic abnormalities like hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. N: Cannabis hyperemesis syndrome, which presents with abdominal pain and vomiting, is associated with frequent visits to the ED in chronic users. J: The mainstay for treatment of cannabis hyperemesis syndrome is supportive therapies and cessation of cannabis use. N: Patients with cannabis hyperemesis syndrome crave hot showers because of activation of the TRPV1 receptor. J: Topical capsaicin may also help in the treatment of cannabis hyperemesis syndrome through activation of the TRPV1 receptors. N: Haloperidol at 2.5mg IV may help in refractory vomiting associated with cannabis hyperemesis syndrome. J: Many children and adults do not believe synthetic cannabinoids pose serious health issues as the they are not illegal to purchase. This is incorrect. N: Most patients with acute uncomplicated cannabis intoxication can be observed and discharged. Admit if there are any signs of end organ damage, intractable vomiting, or acute psychosis. Jeff: So that wraps up the August 2018 episode of Emplify. Nachi: For those of you looking for CME - the address for this months credit is ebmedicine.net/E0818, so head over there right away to get the credit you deserve.  Remember that the you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. See you next time! Most Important References 5. * Kim HS, Monte AA. Colorado cannabis legalization and its effect on emergency care. Ann Emerg Med. 2016;68(1):71-75. (Literature review; 21 studies)7. * Baron EP. Comprehensive review of medicinal marijuana, cannabinoids, and therapeutic implications in medicine and headache: What a long strange trip it’s been …. Headache. 2015;55(6):885-916. (Review)9. * Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. (Retrospective chart review; 4 cases)64. * Tournebize J, Gibaja V, Kahn JP. Acute effects of synthetic cannabinoids: update 2015. Subst Abus. 2016:1-23. (Systematic review; 46 articles, 114 patients)83. * Wallace EA, Andrews SE, Garmany CL, et al. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J. 2011;104(9):659-664. (Review)