Podcasts about jeff more

April was our most downloaded month ever. Thank you to our listeners! Jeff and Will discuss their upcoming travel schedule. They will be at the Romance Writers of America national conference, Podcast Movement, Dreamspinner’s Author Conference and GayRomLit. Jeff reviews Top Secret by Sarina Bowen & Elle Kennedy and Red, White & Royal Blue by Casey McQuiston. Jeff interviews Casey about her debut novel. They talk about the inspiration for Red, White & Royal Blue and the impact the 2016 election had on the story.  In addition, they discuss the recently announced movie adaptation, what got Casey into writing romance and what she’s working on next. Complete shownotes for episode 187 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: Top Secret by Sarina Bowen and Elle Kennedy. Reviewed by Jeff. I’ve been a huge fan of Sarina Bowen’s for some years now. Her Understatement of the Year is among my favorite books of all time and I also love Him and Us which were co-written with Elle Kennedy. Sarina and Elle are back with their first m/m romance in three years with Top Secret. They’ve written an extremely satisfying enemies to lovers romance that sizzles but also has some extremely sweet parts as well. Keaton’s a college junior from a privileged family whose been with his girlfriend since high school. For her birthday, she announces that she wants a threesome. After brief thought Keaton agrees. He lives in a frat house where one of his frat brothers is Luke. Luke basically keeps to himself barely gets along with anyone in the house. Luke’s a townie, going to school on an academic scholarship and as a despicable mom and older brother who only want to take advantage of him. He lives in the frat because it’s cheaper than a dorm and he’s running for president because that means free room. Keaton looks to an app to help find the right guy for this birthday present. He signs in as LobsterShorts and soon ends up talking to SinnerThree. Once SinnerThree finds out it’s Keaton’s first three way, he wants to make sure Keaton would be cool with him in the mix and to start considering what the rules would be. SinnerThree even gives sexy homework. This gets Keaton thinking because he’s buried his feelings about guys for a long time. Of course, SinnerThree is Luke, who lives right across the hall. What makes this book work so extraordinarily well is the two sides of Luke and Keaton we see between their public personas and their chats on the app. Luke wants to escape the town and the life he’s known growing up. He strives to excel in school so he can get the high-paying job and never be reliant on anybody again. Meanwhile, Keaton knows he’s got all the privilege but he also chafes at the expectations that his family and friends put on him and he keeps all that to himself because it’s what he’s supposed to do. When they’re chatting as SinnerThree and LobsterShorts the conversation occasionally drifts from figuring out what Keaton’s boundaries actually are to discussing their realities and what they want out of life. Their emotional shields fall away. The way Sarina and Elle transition from sexy to sweet and back again is perfect. Of course, the night finally comes and Keaton and Luke find out they’ve been talking for weeks. The night doesn’t go as planned, but they don’t stop exploring their sexual feelings or sharing closely guarded secrets. Both guys have great growth as Keaton comes into his own, embracing his true sexuality and the career he wants after college. I’m particularly happy this wasn’t a gay-for-you story but rather about a young man figuring out who he is. The battle for Luke is about his sexuality at all–he’s proudly bisexual. He can’t fathom that anyone could love him because of his terrible family. He’s been so battered by them, that he’s hesitant to accept help from anyone because it would surely come with strings. Thankfully, even though Keaton bungles quite a few things with Luke, he also works to make it right. It’s a credit to Sarina and Elle that they have created such fully fleshed out characters who evolve so much through the story. I was invested in so much more than the romance because I wanted these guys to find their way too. The motley crew of frat brothers also brought some great depth to the story as they were a mix of those who were genuinely kind and others were douchey. The parents were also an interesting contrast between Luke’s trailer trash and Keaton’s very well-to-do. Keaton’s father and mother are far more than meets the eye too. I don’t want to get into spoiler territory, but I have to call out them out too. It’s an example of Sarina and Elle creating multi-dimensional characters. Another extraordinary part of the story for me was how the black moment played out. A lot of stuff goes down and there were plenty of opportunities to cheapen the story. The way the last twenty percent of the book played was perfect even while it provided me with quite a few moments of stress. We’re headed into summer and this book is perfect for vacation reading. I highly recommend Top Secret by Sarina Bowen and Elle Kennedy. Red, White & Royal Blue by Casey McQuiston. Reviewed by Jeff I knew this book would be exactly right for me. I have a thing for the royal trope and the idea of an American first son and a British prince getting together made this a must read. What I didn’t expect was how Casey McQuiston elevated the material putting this enemies to lovers romance on the list of my all time favorites. Alex Claremont-Diaz is the first son. Henry is the prince. They have secretly crushed on each other for years. They developed an enemies vibe at the Rio Olympics when they had a less than good encounter, especially from Alex’s point of view. Move forward to today and a near international incident set off by the two at a royal wedding. As part of PR disaster control, a story is created that Henry and Alex are actually the best of friends. After some forced outings to appease the press they start talking to each other more and get past their public personas. One of the things that makes this story works so well is Casey has created an alternate history that many of us would like to see. Claremont took office from Obama so the Trump nightmare never happened. And it’s wonderful that her son is Mexican-American given the current hate filled climate around immigrants. There’s even a couple of lines in the book about how it’s not lost on Alex that there are some people who hate that a Mexican-American took the job of first son. Alex and Henry talk a lot about the lives they want. They’re both expected to meet family obligations and be leaders for their countries–it’s not really what they want though. The texts, emails and phone calls as Alex and Henry reveal more and more of themselves are absolutely priceless. At times funny and others heartbreakingly honest, they talk about how they feel trapped. As the first sparks of romance blossom between them their enemy side is quite fiery as they have rage filled kisses before succumbing to the fact that this is something that they both desperately want. The back-and-forth between sweet romance and the slightly angry romance enhanced the story as they fight against their feelings. The reality stays firmly rooted throughout the story and I loved that. Sometimes the royal trope, as much as I enjoy it, is far more fantasy than reality. It’s part of what makes the trope so good–that chancea prince might be your neighbor. This world could exist–a prince and a member of the first family. Casey gives them all the trappings, including secret rendezvous’s that are partially orchestrated by their security teams. Of course, as must happen the romance is horribly revealed and damages them both. The guys had to really work for the happy in this book, which makes the ending so sweetly satisfying. There were a lot of ways the end could’ve played out, but I can’t imagine one that would’ve been more perfect than what Casey gives us. I haven’t felt as overall thrilled by a book as I have by Red White & Royal Blue in quite some time. It reminded me of reading Becky Albertalli’s Simon vs. the Homo Sapiens Agenda and the wonder of such rich, vivid characters in a charming story that deserves to be real. Casey captured not only an America that I desperately want to live in but a romance that was everything that I ever wanted. I could gush on and on about this book, and will more in the upcoming interview. For now I’ll leave this by saying that I beyond highly recommend Casey McQuiston’s Red White & Royal Blue. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish Hank Edwards and Deanna Wadsworth’s 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: Casey, welcome to the podcast. Thanks so much for joining us. Casey: Thank you so much for having me. I’m very excited. Jeff: So, before we got to this segment, I spent a ton of time just going over “Red, White & Royal Blue” as being one of the best things I’ve read this year and one of my top books maybe in the “ever” category because it’s everything I needed in a romance with the prince trope and essentially royalty in the U.S. with the first son. And, I mean, Alex and Henry are so awesome. Tell us what your inspiration was behind this book? Casey: Yeah. So I first started…actually, it’s weird. A couple of days ago, I was going through my Timehop which shows you, you know, what you tweeted two, three, four years ago, and I realized that, a few days ago, which is April 13th, was the day that I tweeted, “Hey, I just had this idea for a book.” And it took me back to that moment of the exact lightning strike moment when I knew what I wanted to write. And this is a question we’ll get into later, but it was one of many attempts at a book I had started and none of them had really taken hold of me like this one did. So it was early 2016, I was obsessively following the presidential election, which, you know, we all were at the time with a lot of optimism. And, at the same time, I was reading two books. I was reading “The Royal We,” which is by Heather Morgan and Jessica Cocks, and it’s basically almost a novelization of Will and Kate with a bunch of different things changed about it. So I was reading that. And I was also reading a super dry Carl Bernstein Hillary Clinton biography, which was a fun little juxtaposition. And I had this idea in my head of I want to do… I’ve seen so many sub-versions of prince charming trope, but I feel, as a queer person, I’ve never seen one that seems the most obvious to me, which is, you know, what if, he wasn’t the perfect, going to produce a million heirs, prince, you know. And then on the other side, I was I loved “Chasing Liberty” when I was growing up and “My Date with the President’s Daughter” and I was really into the idea of a rom-com starring this rebellious first kid, and I couldn’t decide which one I wanted to do first, and I was like, “Wait a minute. If I put them both in the same story, I don’t have to pick.” So, honestly, it was me being indecisive that led to that decision. And on a wider scale, a bigger scope, I just really was looking for the perfect, fun escapist tropey rom-com that was so undeniably fun that the fact that it was also queer wouldn’t keep it out of the mainstream, you know, because a big thing that I want to do as an author and as a queer person is push those stories into the mainstream and be like, hey, you know, it’s kind of what they say in “Love, Simon,” everybody deserves to have a great love story, you know. And so everybody deserves to have a big shiny tropey, fun rom-com, you know. So, yeah, that was kind of where it came from for me. Jeff: And there is so much rom-com-y goodness floating in this book. I think you pulled a little bit from everything. Without giving spoilers, because there could be some depending on what you pick for this, what are the rom-com moments that just sticks out for you as one of your favorites among all of them? Casey: Wow, that’s a good question. I have pulled so many tropes from so many of my different favorite rom-coms. But there is this one thing that I love in every rom-com which is the gratuitous karaoke moment, which is actually if you ever watch “Crazy Ex-Girlfriend,” it’s a song on “Crazy Ex-Girlfriend” like “Shake Me Up.” Okay, yeah, that. So it’s like “27 Dresses” does it, and “10 Things I Hate About You” does it where it’s like somebody gets up and sings a song in front of a bunch people for no reason. And it’s like, “No, this doesn’t happen in real life, but it’s super fun.” And so writing the whole karaoke scene, which I don’t think is a spoiler, that was so much fun for me because I was, you know, as musical theater kid in high school, we all were, and so I got to be so indulgent with that, and it was such a blast. I loved it. Jeff: I think you picked a great one right there because you’re right, there is that moment. There’s even that movie, which of course I’m blanking out on right now, that was like…it was a Rebel Wilson movie earlier, I think this year, that she’s, like, there’s always the karaoke moment that she ends up trapped in the karaoke moment in her own little thing. Casey: I love the karaoke moment. Jeff: That says a lot about people, the songs they pick. Casey: It does. It’s character shorthand for sure. Yeah. Like when Bea gets up and sings “Call Me” by Blondie in the book I’m like, “This is what she’s about, you know.” Jeff: Yeah. There have been so many accolades on this book before it even got published. I mean, we were reading about it, I think in “Blush” almost two months ago now. What’s resonating so much with all these pre-readers? Casey: God, you know, I mean, just to start off, I’ve been, completely blown away by the response to it. When I wrote this book I was like, “This is so niche.” It’s a queer political rom-com with royal elements. And also we talk about gerrymandering in it, and I was like, “This is so niche,” no one’s gonna care, no one’s going to publish it. I was like, “I’m going to try and query this for a month, and then I’m just going to self-pub,” you know. And the fact that people have engaged with it so much and that it has gotten, I think three-star reviews now which is just blowing my mind completely, so beyond grateful for those. It’s just been so staggering and incredible. But, I don’t know, I think that right now the world is really depressing. We live in a world right now that is at times literally on fire, you know. And it is so important to have these little oases or moments of respite and little escapist things because when I first started writing this book, I’m so neck deep in the news cycle and I really couldn’t finish it until I pulled out of it because I realized that wasn’t what it needed to be. It didn’t need to be mired in all of the negativity and all of the darkness that was going on in the world. It needed to be this spark of hope, you know, that would kind of feel… I think about when Obama won re-election in 2012, and I was with my friends. I was in college at the time and we went out on the balcony, and popped a bottle of $60 French champagne, and I think about how I felt in that moment and I was like, “I want this book to feel like that moment,” you know. And I think that a lot of people have been missing that feeling. I think that we have so few things, especially when we look at the political sphere right now, to be excited about and to be hopeful about. And I think that we’re all just nostalgic almost for when we had hope. And I think that what this book does is it lives in the space of being here and now and still having hope, you know, and I think that’s really resonating with people. And then I also think that people are just excited to see…we’re seeing it with Helen Hoang and Jasmine Guillory who are writing romances that are integrating, you know, neurodiverse characters and just racially diverse characters. I think a lot of people are tired of seeing, you know, the same two straight white cisgender, neurotypical people falling in love, you know. And so I think that people are hungry for something that’s different in rom-com that can show that different types of people can have that same big, huge, escapist magical love story. So that’s kind of where I think it comes from. Jeff: You noted that you started writing this in 2016, essentially before the election happened. Do you think you would have written the same book had Hillary won? Casey: That’s a great question. And the book I had planned to write before the election went the way that it did was a different book. There were so many threads that I ended up dropping. I, at one point, had…and this was before anything about Russia had come up. I, at one, point had… a Russian double agent involved in the campaign and I was like, “This is too unrealistic. No one’s going to buy this. I’m cutting this,” you know. And now I’m like, “God…” But, yeah. I mean, it definitely…I think it would have been more lampooning the Democratic Party…not that I have anything against the Democratic Party as someone who is registered as Democrat, but it would have been more of “Veep” style, you know, that we’re all on the same side here, so we’re going to send each other up kind of thing. And instead it’s still very tongue in cheek, and it still has that “Veep” side to it, but it needed to have more of…. it needed to be less cynical, basically, you know, because I don’t think that we can really afford a lot of cynicism right now beyond what, you know, roasting the President on Twitter is cynical, I guess. But, yeah, I think that there are certain things that happen in the plot that never probably would have been explored if the results of the election had gone differently because I don’t think I would have felt as much of an urgency to put those into the story. So, yeah, it definitely would have been different. It definitely would have been a lot different. But the President was always the same. President Claremont was the same character from the moment I came up with the idea for the book. She’s like Tami Taylor, from “Friday Night Lights” meets Wendy Davis, the politician from Texas, meets a tiny bit of Selina Meyer from “Veep” and probably every strong female in my life, you know. So, yeah, long story short, yes, it would have been different.  Jeff: One of the things I like about it so much, and you touched on this a little bit, is that it’s not two white guys getting together because Alex is Mexican-American. And certainly given how things have played out under the current administration, having that element in the White House as first son, it says a lot. And Alex comments on this, you know, periodically as he’s kind of going through things and how that aspect of his heritage plays into things. Did you have that set early on or did that kind of manifest as we saw how immigrants were being treated post-election and even during the election cycle for that matter? Casey: Sure. Well, the minute…it kind of was, like, the plot itself that informed what Alex would be because, like I said, the first character I came up with was the president and everything kind of formed around her. And I’m from Louisiana, and I have this huge chip on my shoulder about democrats, and liberal people, and progressive people in red states because I was one for so long. I live in a purple-y state now. But, you know, I feel they’re so often written off and discredited, and I can probably count on one hand the number of actual presidential candidates who came and campaigned in my hometown, which is the capital of Louisiana. And people just don’t see anything worth investing in. So I wanted to do a southern Democrat. I didn’t think that a Louisiana Democrat was that realistic, so I did a Texas Democrat. And from the minute I knew she was from Texas, I was like, “Well, it would make sense for her to have married a Mexican man, or a, you know, a first or second generation Mexican man.” And it just kind of went from there where I was, like, “You know, I really do like that idea of that.” I spent so much time in Texas, I know so many people from Texas, I know so many Tejanos and people… it just made sense to me. And then, you know, the more that the rhetoric kind of got really vitriolic about Mexican immigrants around the election, I was like, “Yeah, fuck you. Actually, I am gonna put some Mexican people in the White House.” Yeah, that’s what’s gonna happen. I did as much as I could with it. Obviously, I’m white, and I did a ton of research, I talked to a ton of Mexican friends of mine, and especially Tejano first or second generation people. And then what I’m really excited about with the movie is that we have the opportunity to bring in more people on the creative side who are Latino who can offer more of that voice, that can go farther than I could go with it and that can explore more things with it. So, yeah. It just felt really natural to me, he’s from Texas, of course, he could be half Mexican. That’s just so typical there. So, yeah, it was a very natural progression of the character for me. Jeff: And in a weird twist, I’m actually interviewing you from Dallas. Casey: Yes, I know. I was just thinking about it. That’s so funny. Yeah. I feel like that’s appropriate. I feel the stars aligned to have you interview me from Texas. Jeff: And finish the book while I’m in Texas. It was kind of crazy. Casey: Yeah. That’d be so appropriate. I’m really excited because my second tour stop is in Austin, and I’m so excited. I haven’t been to Austin, like, a year or two, and it’s just feels so right to go back with this book. So I’m so excited. Jeff: There is a ton of history in this book. Henry goes into a lot of history of the monarchy. And one of the things I loved is in the emails that Alex and Henry are trading, they end up and quote a lot of literature or other letters of historical people. How much of that was in your head, and how much was “I need to go off and do a ton of research?” Casey: So, for me, a lot of…when I was talking about… there’s parts where after Alex starts figuring stuff out, he starts, like, develops independent research of, like, let me remediate myself on queer American history, and reconnect with it, which I think is something that a lot of queer people in their 20s do. Especially for me when I was 20, 25, and then I started to figure myself out, I was like, “Wow, I need to know the first thing about my own community.” And so I went back and really read a lot and educated myself. And so a lot of the American history, American queer history was stuff I was already familiar with because that’s something that I felt was my responsibility to learn in the past. But, yeah, I definitely didn’t know a lot about queer British history at all. And so that was a lot of reading for me, a lot of, you know, finding history threads on Twitter, and then okay, I’m gonna go look up all these stories individually, and find out what’s the real truth, because things get twisted online. But, yeah. The letters kind of started with…and this is gonna date when I started writing this, but I was really coming off the “Hamilton” high, you know, which I think we all were in early 2016. It was like, “Oh, man, I’ve been mainlining Alexander Hamilton history for six months, you know.” And, you know, I was really interested… I love all of Hamilton’s love letters with Eliza, but there was also his letters with Florence that were really fascinating to me, and I had started looking into that and that was how I found this book called “My Dear Boy” by Rictor Norton. And I found that because I was researching the Hamilton Lawrence letters, and that was where I found a lot of the letters that are featured in the emails. And then I also was looking into Virginia Woolf, and Eleanor Roosevelt, and all those figures from history who also have a lot of archive letters that are very interesting. And, yeah, honestly, it was almost…I had a blast with it because it was just a queer history, like Easter egg hunt. And, you know, I intentionally did that in the book because I pictured this book…I pictured it being something that a lot of people at different points in their journey with queerness would read, and I would want…let’s say some 19-year old who’s just figuring things out, and they don’t really know anything about queer history, I’m like, “Well, here’s the name of something that you should go look up.” “Here is ‘Paris Is Burning,’ go watch it,” you know, kind of thing. And so it was, it’s really, a bunch of sneaky history lessons. I’m a nerd, and I was like, “You should know this, too.” But, yeah, I had a blast doing that. And then just research, in general, was just so much fun. I spent so much time poring through the royal collection archives online, just for throwaway jokes and stuff. I was a journalist for six years before I quit to do this full time. And so, yeah, I’m a huge nerd and I love historical context for everything because that’s just what I’ve been wired to do for so long. So, yeah, that’s kind of where it all comes from for me. Jeff: And my musical theater geek self loves that “Hamilton” had a play in that because I kind of felt that I was reading some of it’s like, “This seems very ‘Hamilton’ in some ways that they’re using this.” Casey: I battled with myself over whether “Hamilton” was a thing that existed in this universe, and if I should mention it in the book, and I was like, “I’m not gonna,” because it’s still so fresh and I feel it’s gonna date the book a lot. But it’s definitely, like, there’s this undercurrent of we’re doing colonial rap battles under the text, you know. Jeff: That’s one of the things I like about this so much is that it is current revisionist history, you know, because, I mean, most of it, and this doesn’t get to a spoiler, most of it is leading into the 2020 election, with Claremont being President in the here and now and having succeeded from Obama. Yeah, its current revisionist history. It’s very interesting how that plays itself out. Now, I think we mentioned that this is your first book that’s out there in the world. What got you into writing romance and specifically m/m romance? Casey: I mean, I have always consumed all types of media and this is my one sacrilegious answer that I give in interviews which is I’m really more into movies and TV than I am into books, and that is the most media that I consume. It’s not what I write, I’m not a screenwriter, I’m not good at that type of writing, but it is where I pull most of my influences from, and what I consumed the most as a kid, I mean, unless you count “Harry Potter,” which everybody read… Jeff: Which does very much exist in the “Red, White & Royal Blue” universe, which I also love. Casey: Oh, yeah, very much so. But what I engaged with about all of those things was the relationships in them. I’ve watched “Lost” and I was like, “I don’t care about Dharma, or the clues or what this island actually means to the polar bear,” I was like, “I care about that everybody’s gonna end up together that I want to end up together in the end, you know,” and it was always like that with everything I watched. I’ve watched “Buffy,” and it was always about that for me. It was like, “This is cool, mythology is cool, whatever, but, like, Spike,” you know. And it really that was just what grabbed me, and so I knew that was what I was always gonna wanna write. And I tried to write other genres. Every other book I tried to start writing was young adult, magical realism, or young adult fantasy, which is clearly not my genre. And I tried a bunch of different false starts in those genres, and it didn’t pan out for me. And this was, like I said, the first time, I had an idea that completely grabbed me. And I think, like I said earlier, I gravitate to writing queer fiction for the same reason that straight people gravitate to writing straight fiction which is that I’m a queer person, and it’s my experience, it’s what I know. I didn’t really come into this book with an idea of what the gender should be more than what the story would be and it formed around that because I didn’t think that the story would take on all of the same qualities. If it was two women, you know, I thought that it would be a little different tone. I felt if it was two women there’d be a porn parody within 15 minutes of it coming out, you know. And so it’s just, there’s just different ways that lesbian couples and gay men couples are perceived by the world I felt, and for this story it made more sense with two men, and I also wanted to do that prince charming trope sub-version. And so it just kind of told me what it wanted to be. But my next book is…it’s about two women, and it’s a completely different story. And so, yeah, I really…honestly, it’s just me trying to make queer rom-coms a mainstream thing more than anything else. Jeff: More power to you. And, so far, it looks like you’re doing a great job with that. Casey: Thank you. Thank you so much. Jeff: This question may not have a good answer based on what you just told us about your kind of TV and movie thing, but are there authors who influence you? Casey: Well, yeah, I mean there are definitely authors that influence me. I loved Oscar Wilde growing up which is, you know, I was 15, my sisters, I remember being at my sister’s college graduation with highlighter and sticky tabs going through “The Importance of Being Earnest.” So, yeah, I did my term paper in high school on “The Picture of Dorian Gray,” and I was like, “This is straight behavior.” But, yeah, Oscar Wilde was a huge influence on me. The “Harry Potter” books, yes, of course, they influenced me. I read a lot of non-fiction and a lot of memoirs actually because I love the voice of them, and I think that’s what helps me to have a good narrative voice. So I love Carrie Fisher’s writings, I love…Nora Ephron’s memoirs are all incredible, Mary Karr. Let’s see, what else. I’m looking at my bookshelf right now. What else do I read? Jane Austen, obviously, the classics of romance, you know. And then more recently, my favorite author right now is Taylor Jenkins Reid. “The Seven Husbands of Evelyn Hugo” is my favorite book I’ve read in the past couple years and definitely has earned a spot on my all-time faves shelf. And so that’s definitely… And I loved how she does a lot of…she does a lot of what we call in journalism alternate story formats, so epistolary style things that are threaded into the book, which is something that obviously I really love too. And then yeah, that’s…I mean, I read a lot…at least I read a lot of non-fictions like Rebecca Traister and Roxane Gay, those are those are all my faves. But then I pull from a lot of a lot of TV and movies. The biggest influences on this were “Veep,” “Parks and Rec.” There is this web series called “The Gay and Wondrous Life of Caleb Gallo” that I love, and it’s so millennial absurdity that it really kind of like… there’s a shout out to it in the book because they play the song, “Loco In Acapulco” by The Four Tops in that show, and I put that in the book. Yeah. So I’m kind of all over the place. I have a lot of influences and a lot of things that kind of all feed into what comes out of my brain. Jeff: So let’s talk movie. You hinted that a little bit ago. Amazon and Greg Berlanti picked this up before, you know, again before it’s even published out to the world. What was your reaction when you first heard that that was a done deal? Casey: Well, I mean, it was so many stages of reaction because what people don’t see behind the scenes is that the process is crazy. It starts with I have a Hollywood agent, and she sends it out to people and then one producer expresses interest and then more producers can if they want to, and then it turns into you’re on the phone with, you know, such and such from whatever huge production company, and it’s like, “I’m not qualified to do this.” And you talk to those and you pick your producer, and that’s how I picked Berlanti. And I was just really excited to even have a chance to work with them because I’ve loved so much of their work, not even just looking at “Love, Simon,” and going back to “Political Animals” which was a six episode series that’s on Netflix. It’s got…honestly, I have to say one of my touchstones too because it’s got Sigourney Weaver is the president in that which is just amazing, and they’ve got Sebastian Stan as one of the president’s kids, and he’s very tortured, and recovering from addiction, and he’s gay, and he’s Sebastian Stan so he’s crying, you know, and very beautiful. But, yeah. So I just knew that he had the range for it and I also knew that based on “Love, Simon” that production company had the chops to get an unapologetically queer rom-com into the mainstream. But also it was on a personal level, I just remember going to see “Love, Simon” in the theater and that was probably a week after I signed my book deal. And I showed up with an entire eight-inch Jimmy John’s sub in my purse because I knew I was going to cry and I like to eat my feelings. So it was literally me alone. I had to drive 15 minutes out of my city because I was living in Louisiana at the time to find a theater that was playing it, and it just me alone in the theater with my sandwich and was just weeping to Jennifer Garner, you know. And I just remember getting in my car and thinking if my book could make people feel half as seen as I just felt by watching that movie, then I will be so, so happy. And so I’d have the chance to do, to kind of pay forward what that feeling was for me to the next round of people, especially queer people, meant so much to me. And then yeah, Amazon, they just care so much about the project. They’re so passionate about it. They want it to, you know, really…they’re actually really invested in diversifying what is in the market, and taking some risks, and doing projects like this. And it’s just so incredibly mind-blowing, and it really doesn’t feel real yet to have people want to invest those kinds of resources in a story that I wrote. More than anything, I’m just so excited about what it could represent and what it could mean to people. I think about like…and not to at all compare the histories of these communities, but I think about “Black Panther” and “Crazy Rich Asians” and what those movies meant to have as big cinematic events geared around a demographic that wasn’t usually catered to by the mainstream, you know, and what it meant for those people and what it represented for the future of storytelling for different groups. And I like the idea of being able to make any kind of similar impact with movie is incredible. And I really hope that we can do that, and I really hope that it can be the beginning of a lot more queer rom-coms, you know. So, yeah, it’s amazing. I’m so, so humbled, and amazed, and really excited to see what comes next with it. Jeff: As you were writing, I think all authors tend to cast their books to some degree. Do you have in mind, and knowing this is totally separate from anything that Amazon and Berlanti might do… Casey: Sure. Sure. Jeff: …do you have in mind who Alex and Henry are, at least in your head, as you were writing if you had to assign them an actor? Casey: Well, it’s so hard because…and this is kind of an indictment of the state of Hollywood and that is slowly beginning to change, but there really aren’t a lot of young Latino actors out there choose from, you know. And so it was… there really wasn’t a definitive Alex in my head because I have looked and looked and it was so hard to find someone that fit. And that’s what’s exciting to me about the movie is I think that we will get a chance to kind of give a star making role to some young unknown Latino actor, which would be amazing, and I would love to do that. And Henry is just very elusive. There’s five million charming white British men, but in my head, he’s just so specific-looking, and I have not yet found anyone that matched him. But the parts that were, I think, easiest for me to assign an actor to were like… I always pictured Daniel Day-Lewis as Richards with like the silver foxy and then, Ellen Claremont in my head from day one has been Connie Briton. And then, I mean, Rafael Luna in my head is Oscar Isaac for sure, you know. Jeff: Oh, yeah. I like that. Casey: There’s some characters that I came up with the character first and then tried to figure out what they looked like, and there are other characters where… with Rafael Luna I was like, “I want a character who looks like Oscar Isaac. What’s he going to be?” you know, and that was kind of how that came to be. But, yeah, I’m really excited casting is going to be so much fun, and I’m very excited about it. And I’m really, really excited about just getting to see, you know, what we can do for some…I think there’s gonna be a lot of unknowns in the lead roles, and that’s going to be amazing because they’re going to be able to really step into and embody those characters without it being distracting, like, “Oh, that’s like so and so. I look at them and all I see is the character they played in ‘Game of Thrones’ or whatever.” Yeah. so I think that’ll be, you know, a fun thing. But, yeah, that’s kind of it for that. Jeff: Do we get to see more of Alex and Henry in the future do you think? Casey: I think that I would not rule that out, and that’s all I can really say about that. Jeff: Sure. Casey: Yeah. I think that that would be amazing. I would love to do that. Jeff: And you mentioned your next book is going to be a female pairing. Casey: Yeah. Yeah. So it’s completely different from this. It’s a much smaller scope of a world. It’s just a girl who moves to New York, and she’s from the south. I don’t think I will…I don’t know if I will ever write a protagonist that’s not from the south because that’s just so deeply ingrained in me and in my voice. But she’s from south, she moves to New York, and she kind of stumbles into this roommate situation where it’s just sort of ragtag band of misfits kind of thing. And she develops this huge crush on this hot chick who’s on her subway commute every day. And it’s kind of based on the idea of that way that you fall in love with something on public transit for like 20 minutes, and then you step off, and it’s like they never existed anywhere other than the train. They’re just there for 20 minutes, and you never see them again. But the thing is that she sees this girl every single time she’s on the train. And there’s kind of a twist as to… I will say there’s some light rom-com-y style time travel shenanigans that happened, and the girl on the train is not exactly everything that she seems. And so the whole book is about their relationship and at the same time trying to figure out what’s going on with this girl. But it is rom-com, and it’s super fun, and, of course, it has a gratuitous karaoke moment. Jeff: Excellent. Casey: Well, it’s more of like there’s a gratuitous karaoke moment, and there’s a gratuitous drag show moment. Yeah, so, range. But I’m really excited it. I’m hoping…I mean, obviously, we haven’t set a date for it yet, but it is super, super personal, book of my heart for me, and I’m really excited for people to read it. Jeff: Fantastic, definitely looking forward to that. Casey: Yeah. Yeah. It’ll be awesome. I’m excited. Jeff: What’s the best way for folks to keep up with you online so they could track your progress with what’s up with Alex and Henry and also the new book and everything else? Casey: Yeah, Twitter for sure. I’m kind of been taking a step back lately because since we announced the movie my notifications have been busted, you know. But, yeah, I’ll definitely be back on more especially during tour. I tweet out playlists and a lot of little trivial information like their birth charts and things like that on there, and then also Instagram. That one is more for like I’m here for this tour date kind of thing. So yeah, those are my big two ones. It’s casey_mcquiston on Twitter, and then casey.mcquiston on Instagram. Jeff: Very cool. Well, we will put the links to all of that in the show notes. Casey: Thank you so much. I appreciate it. Jeff: “Red, White & Royal Blue” comes out on May 14th, and we wish you just continued success because it’s been so much already and look forward to seeing the movie and everything else that comes from it. Casey: Yeah, thank you so much. I’m so, so grateful, and it’s been so much fun. So thank you so much for having me on.

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)

Wild-caught versus farm raised. Astronomical mercury levels. When you order fish at restaurants or purchase it at your local grocery, you have so many decisions to make. It can become confusing! Yet fish is one of the healthiest foods you can eat, thanks to its omega 3 fatty acids, protein, and nutrients. In this podcast, Jeff More busts popular fish myths and discusses the best choices that belong on your plan to minimize mercury levels as well as other problems you confront buying and eating fish today.