Podcast appearances and mentions of jeff most

New monthly bonus feed here! https://www.patreon.com/rockfilmrock This episode is dense and detailed as all hell. I say that every few months about a new episode, it's true. But this really ranks up there with my Janis Joplin, Chris Cornell, AC/DC and Doors episodes in the amount of research (see the many references below) and interstitial music edits involved. So thank you in advance for your indulgence. This one covers:  An expanded history of James O'Barr's journey from the USMC to optioning The Crow for a development deal Joy Division's early gigs, record deals, recording experiences, and Ian Curtis's death Trent Reznor's trials putting together the "Pretty Hate Machine" era Nine Inch Nails lineup, touring as an opening act, 1990s ascension as the eternal outsider, generally underreported backstage raucousness and the eventual shift into "Downward Spiral" The many steps between "The Crow" as a comic book released independently out of Detroit to nationwide distribution to screenplay revisions to script revisions and securing a serious-ass movie deal for real. Featuring accounts of Jeff Most and John Shirley who made it happen Clashes and controversies behind the scenes between writers, producers and director of the film, extending all the way to what DVD features we've still been denied due to legal squabbling that took place even years after the film's release PayPal tips: https://www.paypal.com/paypalme/whatsamatta Shirt designs with defeatist messaging delivered via bright colors and childish graphics: https://www.bonfire.com/store/justtheworstshirtsever/ Subscribe to me on YouTube: https://www.youtube.com/channel/UCV4Up7xGgjioEC07bjwu4mQ Follow on Twitter: https://twitter.com/RockFilmRock Follow on Instagram: https://www.instagram.com/justtheworstever/ Send me an email with show suggestions: Justtheworstever@gmail.com Suicide Prevention, Text/Call: 988 https://afsp.org/ National Sexual Assault Hotline 1-800-656-4673 https://www.rainn.org/resources https://www.filmstories.co.uk/features/the-crow-chronicle-the-dvd-extra-feature-that-got-pulled-late-in-the-day/ https://sewermutant.com/the-crow-creator-james-obarr-s-early-years-2b0b6e0ee8d3 https://archive.org/details/Mondo.2000.Issue.05.1991/page/n65/mode/2up?q=Reznor https://archive.org/details/electroshock00greg/page/38/mode/2up?q=Reznor interview 1994 Deborah Curtis's book: https://archive.org/details/touchingfromdist00debo/page/134/mode/2up BROKEN: https://archive.org/details/NineInchNails-Broken/Nine+Inch+Nails+-+Broken.mkv Bootleg library: https://archive.org/details/NIN_starterpack Crow book: https://archive.org/details/makingofcrow0000bais +  Official Making of The Crow book https://archive.org/details/synthgods0000unse/page/106/mode/2up?q=Reznor Self Destruct Book: https://archive.org/details/nineinchnailssel00huxl/page/n5/mode/2up?q=Reznor SPIN MAGS: https://books.google.com/books?id=td2yO_T3DPEC&printsec=frontcover&rview=1&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false https://books.google.com/books?id=xbtTqjWx8FsC&pg=PA70&dq=Trent+Reznor&hl=en&sa=X&ved=2ahUKEwijvPyPqJ39AhVYFjQIHZ19AgUQ6AF6BAgEEAI#v=onepage&q=Trent%20Reznor&f=false https://books.google.com/books?id=3_7wN22l43MC&pg=PT44&dq=Trent+Reznor&hl=en&sa=X&ved=2ahUKEwicodapqJ39AhXTLH0KHS9xABY4FBDoAXoECAsQAg#v=onepage&q=Trent%20Reznor&f=false  

Tom Welling and Jeff Most, star and co-creator of new action drama Professionals, discuss the series from Germany's Leonine Studios set for Viaplay and RTL; and Magnify Media CEO Andrea Jackson talks about the recent sale of her distribution business to Plimsoll Productions, plus this year's virtual version of Mipcom.

Without question, the last several months have accelerated ecommerce adoption and drastically changed consumer behavior. The entire sales lifecycle from finding a prospect to closing the deal has been turned upside down. Now two key obstacles lie in the path of ecommerce leaders… The first is the more obvious, more discussed problem: How do you operationally and technically need to change to meet your customers' evolving needs?  The second key obstacle is not as often addressed, but is equally as important: How do you then communicate to your customers that even in these changing times, you are equipped and ready to meet their new needs?  The binding and laminating business doesn’t sound like it would be ripe with insights into answers to both of these questions, but Jeff McRitchie, the VP of eCommerce at Spiral, is here to prove that assumption wrong.  Jeff has nearly two decades of experience in the ecommerce and digital space. Just last year, his own company, MyBinding.com, was acquired by Spiral, where he now helps lead ecommerce operations. On this episode of Up Next in Commerce, Jeff explains what it has been like merging his ecommerce business with a more traditional binding company. He shares some of the challenges he faced along the way, and what methods and strategies he’s leaned into to find success. Jeff also discusses tips for building out a winning SEO and content strategy, and how ecommerce is playing a larger role across the entire business, including in customer acquisition and content marketing.  Main Takeaways:   The Merge: When a primarily ecommerce company merges with a larger more traditional business, there are a lot of balls in the air to create a cohesive and efficient system. Most of the adjustments have to be made on the side of the acquiring company, which needs to learn how to compete in a digital marketplace. That means that education has to be a priority both internally and externally.    Use Their Words: Every industry has jargon and industry-speak. It’s easy to fall into the trap of using that language throughout your platforms and channels. Instead, you have to meet customers where they are with their own language, and use the words and phrases they use. This will ensure that your customers feel like you are speaking directly to them and it also helps create more longtail SEO opportunities. Content For Now that Pays Off Later: Some of the most-viewed content you create might be consumed after a customer makes a purchase. On the surface, that might make it seem like content-creation is not a good customer acquisition strategy. On the contrary, it’s actually a critical long-term strategy in the sense that good, useful content is critical for brand awareness and building trust, which customers will remember when they need to buy in the future. For an in-depth look at this episode, check out the full transcript below. Quotes have been edited for clarity and length. --- Up Next in Commerce is brought to you by Salesforce Commerce Cloud. Respond quickly to changing customer needs with flexible Ecommerce connected to marketing, sales, and service. Deliver intelligent commerce experiences your customers can trust, across every channel. Together, we’re ready for what’s next in commerce. Learn more at salesforce.com/commerce --- Transcript: Stephanie: Welcome to another episode of Up Next In Commerce. This is your host, Stephanie Postles. Today on the show, we have Jeff McRitchie, the VP of Ecommerce at Spiral Binding, My Binding and Binding 101. Jeff welcome. Jeff: Thank you. Stephanie: Thanks for coming on the show. I was excited when I was looking through Spiral's background. It looked like you guys started in 1932. Is that right? Jeff: Yeah. I mean, we've been around for a long time. Stephanie: Yeah. I think that'll make for a really fun conversation because I'm sure that the company and you have seen a lot of transformation over the years, so that'll be fun to dive into later. Jeff: For sure. Stephanie: Tell me a bit about Spiral. What is it? How do I think about what you guys do? Jeff: So Spiral is really a company and we've built ourselves around helping people to bind presentations and proposals. We do a little bit of laminating. We do a little bit of other things, but really we focus a lot on binding. We sell the equipment and the supplies for people to be able to bind presentations, proposals, books and training materials. Those are probably the primary things that come out of it. Jeff: We're a niche player in the office products market is one way to think about it. We're an interesting a hybrid of a company because we sell a little bit in B2B, a lot in B2B, a lot in B2C or B2B to C sort of space. Then we also have some really interesting national account sort of business as well. Kind of a little bit of an evolving company, we're a manufacturer and a distributor at the same time. We have lots of different faces which presents some really cool challenges from the standpoint of being in a digital transformation or Ecommerce role. Stephanie: Okay cool. So how long have you been at the company for? Jeff: My story is interesting, actually I'm co founder of a company called My Binding about 17 years ago. Last year we sold to Spiral. I've been with Spiral for just over a year now in this sort of digital transformation role but with My Binding, which was more of a pure play Ecommerce space. We grew and we were the largest sort of binding Ecommerce player in the market. Then all of a sudden we joined forces essentially with Spiral, which was the largest sort of B2B player in the market. Now we're one force together going after the binding and laminating market. Stephanie: Oh, interesting. What was that process like where you had your own company, you guys were selling online and then joining a company that maybe wasn't doing as much of that. What was that process like when it came to incorporating your company into an existing older company? Jeff: There's definitely some upsides. Suddenly you have increased purchasing power, you have more access to talent and capital. Those were amazing things, but the integration side of things is tough. Jeff: I mean, you're trying to merge systems and figure out how everything works together and learn the language of a new company. Some of that stuff is not as easy as it should be, as well as trying to figure out where exactly are they on the landscape of digital transformation and how do you navigate that when... We were pretty much an Ecommerce or digital first organization. That wasn't really their background. Now we're figuring out how do we be both? That's a pretty big challenge actually. Stephanie: Yeah. That sounds really difficult. What does the customer journey look like for Spiral or what did it look like compared to My Binding? Jeff: I guess the best way to think about it would be that in a B2B, B2C sort of Ecommerce experience, we were really building our business around a large number of transactions with a large number of customers, essentially small transactions to a large number of customers. On the more traditional B2B model, the traditional side of the Spiral business would have been around a small number of transactions to really big customers. Which is pretty typical when you look at this idea of traditional B2B and more like an Ecommerce B2B sort of experience. At least a B2B, to C sort of experience. Jeff: That was the really interesting thing is that we were dealing with customers from all over the country that in almost every industry that you can imagine, but most of them were rather small and we are filling specific needs for those customers. That was fine. On the spiral side you were looking and saying, hey, they had deep relationships. Relationships that went back decades, in many cases, with organizations where they were the supplier of choice. They had complex contracts and all those kinds of things. That was never really part of the Ecommerce world. Trying to figure out how do you merge those two together to get the best of both. It's not easy, but it's really fun actually. Stephanie: Yeah. I can imagine it takes a lot of training for their existing customers who are used to those contracts and used to things being done a certain way. How are you maybe going about training the customers who are used to doing things the old way to be like, Hey, we actually can do this online usually. Jeff: Slowly. Stephanie: Any lessons there that someone can take away if they're going through the same thing right now within their org? Jeff: You don't have to do it all at once. Our approach is really to allow customers to interact with us the way they want to interact with us by giving them better options. Really the priorities for this past year have been to try to integrate systems and then upgrade our footprint so that we can allow the company to put its best foot forward. Really starting with the E-comm side and getting everybody on the same platform and then tied into the same systems. Jeff: Now we're actually probably just a couple of months away from launching our brand new B2B E-com experience for the traditional spiral customers. Essentially we have been allowing them to continue to exist and deal with the company in the way that they used to while improving the experience and then bringing the platform up for the entire organization. One of the things about especially B2B commerce is that it gets really complicated as you tie in lots and lots of systems and a lot of interesting rules. Jeff: Customers want to deal with you in the way that they want to deal with you. What we've found is that we have to build specific experiences for our different customer types. That's the approach that we've been taking. I think that's a good approach from the standpoint of, you're not trying to force everybody into the same sort of experience because not everybody wants to deal with it in the same way. As a large organization that sort of deals with these sort of different challenges, we have to answer questions, like, do you display pricing on the front end of your website or is it a login only experience? Jeff: What pricing do you show people or what price pricing do people get and how do you control that and how do you manage that and how do you make sure that that experience is personalized for individuals? Then there's the age old question, which is really challenging in an organization that has multi channels and that is, how do you deal with the channel conflict? Whose customer is that? I guess it depends on who you would ask because everybody thinks that the customer is theirs. Yet ultimately the customer needs to deal with the organization in a way that the customer feels the most comfortable, not in the way that the organization feels most comfortable. Stephanie: Yeah. That makes sense. What kind of legacy or what things did the legacy customers get hung up on the most when you guys are making this transition and trying to show them that a new platform's coming? Is there similar themes of things that they're like, oh, I don't feel comfortable with that, or, I don't want to move because of this? Jeff: I think when it comes to customers, most customers want technology. I mean, they become comfortable. I think that they don't want to lose functionality. That's been probably one of the hardest things is that even if that functionality wasn't the best, they become comfortable with it and they don't really want to lose that. Yes they do want a best in class experience. One of the hard things that we all have to deal with in Ecommerce right now is that the bar has been raised. Jeff: There are people who want more and more features in terms of their online shopping experience. What you find is that you need to be able to roll these things out, but you need to make sure that it doesn't make things harder on those customers, especially long time corporate customers. They are really dependent on these things working smoothly and easily. That's actually one of the hardest challenges in this process has been, okay, well, we've done a lot of cool things for customers over the years. One off, you build a feature on the website just for that one customer. Jeff: Well, trying to then redo that and not lose a substantial amount of functionality for specific customers, especially large customers that you have these really deep relationships with, that's pretty tough. Stephanie: I was actually going to ask that next, when you mentioned that you were personalizing the experience for certain customers to make them feel more comfortable or hearing what they want and trying to incorporate that into the platform, how do you go about picking out what things you should maybe personalize or give to the customer without going down a worm hole of having a personal experience for every customer? Jeff: Ultimately, we're taking an approach of first saying, what's the best in class experience that we could build. What are the things that are going to be the best for all of the customers and then looking and saying, "Hey, can we in our roadmap put in the flexibility to accommodate for these many things that customers have asked for?" Jeff: How could we build this in such a way that we can add that on or this on? I'm not sure that we always nail it just from the standpoint of... It's pretty tough to keep everybody happy. But we're taking the approach of, hey, we can make it substantially better for everybody. It may not be perfect, but it should be a dramatic enough improvement that they'll recognize that we have their best interest in mind. Stephanie: It seems like some of those requests might also fit other customers as well or it might be something where they're like, oh, I actually wanted that and never thought to ask. It could be helpful when it comes to product development on your side, like technology development. Jeff: Yeah, totally. We had a really good team that we used to build out stuff and we're able to iterate fairly quickly. That's the good news because sometimes we miss something and so... But as long as you can respond fairly quickly to a customer's need, it gives you an opportunity to serve them better and to communicate. But the other really important part of this is really getting the account managers and your sales people involved in this process so you get some really good feedback because one of the challenges that we face at least is that sometimes as the E-com department and on the technology side, you don't always get raw feedback. Jeff: Maybe the stuff you're hearing is from the people who are yelling the loudest, not necessarily from the people who are trying to help you. You're not necessarily hearing about the features that are going to make the biggest difference for most number of users. Stephanie: That makes sense. With this whole re-platforming and new tech stack that you're going to be launching what pieces of tech are you most excited about showing to the customer or bringing online that maybe wasn't there before? Jeff: For us it's really about an enhanced user experience. We kind of been a little bit on the old school side on the traditional B2B piece of it. This gives us the ability to provide a really much better experience end to end in terms of transacting with us. Some of the things that we're aiming for, that are harder than I was thinking they would be, would be real time freight quoting. When you're a B2B company and you've got a distribution network across the country, and you're trying to figure out how much that pallet is going to cost to go to this customer. You think, hey that should be super easy. That's like in the Ecommerce world, until you start to realize, well, it's really important that you get that right. You have to first know where all that's going to ship from. Jeff: One of the biggest things is a really deep integration with our ERP so we can understand where the inventory resides and then how much it weighs and the sizes and all those kinds of things so that we can do that on the fly. Because right now we do an add back type thing. We'll tell you what the freight is later. Customers don't like that. Especially not in the Ecommerce world. Getting that upfront, same with sales tax calculation. Right now, a lot of that's done on the backend and people want to know upfront. That means building a system that has management for resale certificates and all of those pieces. Jeff: I need to understand where are you exempted, where you not exempted and what are you exempt from and all of those kinds of things so that I can quote you and tell you what the sales tax is going to be upfront before you place your order. That's another piece of it that we're excited about. Requisition list is another one where people will have their own custom price list in the system where they can quickly order. We're building a system where they can upload an Excel file with all of their items that they want so they can do quick ordering and quick reordering. Jeff: I guess those would be a few of the systems. Like a quote management system to allow people to request pricing on items and then for us to respond to them live and track that inside of our system is another one that we're building. Those are all areas where we're saying, hey, this could really enhance the user's journey and make it a lot easier for them to do business with us. Stephanie: That's great. Yeah that sounds like some great changes. Have you had any customers trying out the platform as beta testers and have you seen any difference when it comes to average order value or anything? Jeff: We're not quite there yet. We finished design and we're in the midst of development at the moment. I would say that that's going to be one of those steps prior to launch. Will be first to have sort of sales associates and account managers jump into the platform and test it for themselves and then to really get especially key customers in the system testing, and then also giving us feedback. What do they love? What did they not like and how can we make it better for them? That's on the roadmap before launch to be able to say, "Hey is this better for you?" It's funny because on a traditional B2C Ecommerce launch, you'd be focusing so much on the front end. Jeff: Like, the My Account pages are taking just as much time for this site because that's where our customers are living. They want to use the search, but they really want to use the my account pages. They know what they want, and they need to be able to quickly reorder it. They need to be able to see their orders. They need to be able to have the ability to upload those requisition lists. It's a little bit of a twist but getting them, especially into those my account pages so that they can spend some serious time understanding their accounts and telling us what they like or what they don't like is going to be really important for the launch process. Stephanie: Yeah. That's really interesting about focusing on my account page and how much time they're spending there. I'm sure that things like product suggestions or also bots might be very important on that page to help showcase items that maybe they wouldn't otherwise buy when they're just quickly uploading something or just reordering. Are you guys experimenting with some of the suggestion features? Jeff: Most definitely. Yeah. That's part of the vision is to try to figure out and say, okay, we have these deep relationships with customers and they buy specific sets of products. How can we expand to purchasing a product set? How do we get them and introduce them to complimentary products and show them the right pricing and the right place so that they can say, "Hey, I should totally add that on." That's something that I should consider. It's an interesting challenge for us because we have different personas or groups of people that we're dealing with. Jeff: On one hand we're dealing with dealers and they're really reselling product. You're trying to show them maybe categories of product, where do they need to expand because they're buying for specific purposes. Then you have end users and those end users you might want to show them a different size or a different color. We're experimenting with what the best algorithm is that we can use to show them the right products and then also in the right places too. Stephanie: That's great. What tests are you most excited about that you're pitching to everyone right now and some people maybe aren't sure about? Jeff: I'm actually most excited right now about the lead gen side of our business. Stephanie: Tell me more about that. Jeff: When you start to think about what the power of Ecommerce is for a B2B organization. Ecommerce can really become the engine that powers the acquisition efforts of a company. Especially because we can get in front of hundreds of thousands of customers a month, whereas the traditional B2B sales force might only touch hundreds of customers per month. Maybe thousands, but definitely not hundreds of thousands. Jeff: The idea of... What does it take for us to build a really cool robust system to not only bring these leads in but then to try to figure out how do I score these leads and then not only take them and turn them into an immediate sale, but to determine which ones of these really can be turned into those more traditional B2B accounts that we have these deep relationships with that are going to buy from us for years to come, many tens of thousands of dollars, right? Jeff: The really exciting part to me is looking at it and saying, okay we are on the Ecommerce side, on the B2B2C Ecommerce piece of it. We almost have too many leads. We get so much traffic that comes in. So then how do you figure out, take all those leads and build a really robust system where you can make sure that they're getting exactly what they need, and you're closing as many sales as you can, but then how do you figure out a way to pass those accounts up, the right accounts to the right people so that you can build them into a much larger long term sustainable program. Jeff: For us, that means building a really cool inbound sales team that makes sure that we take care of those leads and that we foster them and do all the things that we need to do, but then building an outbound sales team as well that's going to go in and then say, "Hey, let's take these leads and take them to the next level." Then also figuring out a system for passing accounts up and down inside of the organization. You really want to be able to pass a lead up or a customer up that has substantial potential to be either a national account or what we'll call an enterprise level account. Jeff: But you also want the reciprocity of getting those accounts back or the smaller accounts back from the team. I will say that no one wants to give up that account. That's a big challenge inside of an organization when you're trying to say, "Hey, I'll give you some, you give me some." The way usually ends up being is someone... Everyone wants to receive, no one wants to give. But the system only really works if you can give the best to the... But then also that you can receive quality back. For instance, handing back to the E-com team, only the accounts that don't do any business, isn't really a win. Jeff: You really want your enterprise salespeople focused on enterprise level accounts. We're having to sort of wrestle through what does that look like in terms of structure. I don't know that we really have it all figured out yet, but it's a cool idea. Stephanie: I'm guessing there's a way to automate that and create rules. So it, like you said, can go up or down depending on certain criteria from when they're coming in. How are you all thinking about automating that process? So it's maybe less of a salespeople having to give and take and whatnot, and more like, Oh, this is automatically routed to you based on these metrics. Jeff: That's exactly what we're doing. We're exploring machine learning and big data to try to figure out a really good way of scoring customers because using that scoring, you can figure out how to pass customers up. Then a set of rules as well that says if these customers aren't of a certain size or if they have this kind of profile, they really belong in this group. But it's an interesting challenge from trying to figure out where do you get all this data from, and then how do you process it? We're exploring different options right now in terms of what that might look like and how we can best approach that without spending a ton of money before we bet that it actually works. Stephanie: Yeah. That's really cool. So outside of the prospect giving that information, what kind of things are you looking into right now to find the information to help with that scoring process? Jeff: It's actually challenging. You have certain pieces of information that are given to you which you have usually a name and an address. Their email address usually has a domain associated with it, especially in B2B. So you can pull a lot of information from that and you can start to sort your domain, your customers by domain. But really we're looking and saying, okay, well we do know the purchase history. The idea then is, okay, if you were to sort all your customers out, you can sort them on a scale of, let's say a one, two, three. You can say my best customers spend the most money with me. My worst customers spend the least amount of money with me, but that really misses part of the point. Jeff: You almost need to add a second access to this, which is really about customer potential. When it comes to customer potential, we're looking at the idea of what would it take for us to add some big data to this? To understand the size of their company and the profile of the company that they come from, or the industry that they come from as well, because the industry can be really important to us. But then the other side of it is also looking at what they purchased. Like for instance, people who purchase specific equipment or supplies, they're going to have a much higher lifetime value with us because those are proprietary or have maybe a really good pull through rate. Jeff: For instance, it may not be that it's a proprietary supply, but when you buy that machine, you have to go through a lot of supplies to make it worthwhile. You look at the data and you say, okay, that customer has a huge amount of potential. Not because of the amount that they bought from us, but because of what they bought or who they are, the company that they work for or their position. We're looking at the possibility of maybe even extending that into some of the databases out there that help you understand whether people are in market and what their roles are as well. Jeff: Because when you're dealing with B2B, you're not really selling all the time to the company, you're selling to a person inside of the company and that person has a role. You have to figure out, okay, well what role do they play in this picture? That helps us to sort them into personas. If you're dealing with a really small number of accounts, you can figure this out, but we have to automate it because it's not really feasible to do that in a one off basis. Stephanie: Yeah, definitely seems like you're going to need a whole entire data or business operations team who can build those rules out for you and have dashboards. That seems like a big project, but well worth it. Earlier, you mentioned that you guys have more traffic than you know what to do with and lots of leads coming in. Of course my first question is how are you getting this traffic? How are you acquiring potential customers? Jeff: Sure. I mean... We're in a niche industry, right? So that's part of it. We've been around for a really long time. Because of that, at least... Spiral has been around 80 years, My Binding for almost 20 on the web. As you start to look at that, we created a massive amount of content. Thousands of videos and pages. We really have in a lot of ways, the best websites in our sort of space and industry. Because of that, people are finding us to solve problems. What you find is that we built out these websites and either through SEO or through paid search we're driving a ton of traffic to the websites because they convert and that makes a ton of sense. Jeff: We're essentially... We have all of this content and it's really designed around this idea of how do we solve these problems for customers? We can drive more and more of that content. The website deals with a certain number of those sort of leads and converts on its own. The challenge for us tends to be, what do you do with the people that are maybe a little higher in the funnel? You're now talking about making sure they have a really awesome call center that is going to be able to answer those questions. Live chat is really big. We've extended our live chat hours all the way to midnight which is unheard of in the B2B space. Jeff: I want somebody there to talk to somebody if they have questions about products. Especially really big products. We're experimenting with the idea of doing triggers for live chat. We did that and that was really successful for us. We turned on the trigger and said, with the idea of if I walk into a store, somebody says, "Hey, how can I help you?" We did that on the Ecommerce site and we had massive numbers of people that were engaging with us. But the surprise to us was that many of those people were actually much higher in the funnel than we were used to dealing with. Jeff: In other words, they were now engaging with us and they weren't ready to buy. They were in the research space and they had lots of questions. Which is really cool but it just changes the model a little bit and you all of a sudden have to figure out how do I step up for that? How do I make sure that I have the right person to answer those questions? That's part of it. Driving the leads really comes to how do you acquire traffic on scale? Really good high quality traffic for the site. Then the question is, well, what can you do with it? Driving the traffic is really exciting from a standpoint of it doesn't have to be done in one way but you have to be maybe a little bit creative to do it because you really are trying to get in front of people that have problems rather than... Jeff: At least in our space, you don't come to a binding website unless you have a problem that the binding website can solve. It's not exactly an impulse purchase. You're going to show up and you're not going to just browse around. I wonder what kind of binding machines they carry. You probably are on a mission to solve some sort of problem. Right. Whether that's like your bosses told you that you need to buy a binding machine or you need to upgrade the way that your reports or presentations are going to look, or you have a deadline of Friday and you need to get these reports out for the annual meeting. Jeff: These are all sort of really common sort of scenarios and so then the question is, will this product work for my specific needs? That's a question that our customers are constantly asking. Building to that has been a really great sort of acquisition model for us to build around the idea that every customer that comes to us comes to us with a problem that we can solve for them, and then figuring out how do you work backwards to that? What problems could we solve? Then as you start to get creative with that and build massive amounts of content, that content lives out there forever. That's been really a big part of our success, is really the longevity but also the content generation sort of machine that we've built over the years. Stephanie: How has your content... What is the style now today? Is it only educational? Is it humorous and how has it evolved over time? Jeff: We've tried a lot of things over the years. We've tried to be funny. I think we think we're funny sometimes. We've tried a bunch of different things. We've tried to be really educational. It was really hard to figure out the ROI of that. What we've really... If you were to look at our content, we do a lot of content that is really close to the bottom of the funnel, but that would be really helpful. We go with that sort of helpful thing as well as deep. So the idea of building out a really robust and large set of content over the years about products. Jeff: We spend a lot of time making sure that we have all of the details about the product, even to the point where our competitors come to our sites to look up products because they don't have as good of information as we do. That's one piece of the content side of things for us. We have a lot of how to videos. We did a bunch of experimenting around the videos. We found that the videos that people really cared about would basically answer a couple of quick questions. But mostly it was, will this product work for me? How does this thing work? Jeff: We made a whole series of those videos, almost five thousand of them that are really around the idea of how does this product work and a quick demonstration essentially. Usually around a minute long that takes the product out of the box, show someone how to use it. Those really work well for us because they show a customer generally what are they looking for. A lot of customers they want to see what it looks like or they have a machine already and they want to say, "Is that's the thing that works with my machine.? They don't understand our language. Those videos have worked really well for us as well. Stephanie: That's great. Are there any surprising pieces of content that you didn't think would work that did, or surprising sources of customer acquisition that you wouldn't have looked into before? Jeff: We've had a few blog articles that have found traction in the world and the web that I wasn't really anticipating. We've written a lot of content over the years. Most of the blog articles get a little bit of traffic. They're like evergreen content, little bit of traffic over a long period of time. But occasionally we'll end up with one like... Something about how to laminate without a laminator. Stephanie: That's a good one. Jeff: Amazingly, there's a lot of people that look up that and I was shocked. It consistently drives more traffic than almost any other blog article for us. Which is odd. I'm not sure it drives a ton of business because they don't want to buy a laminator, but if you think about it, there's a whole segment of people that have maybe problems that we don't traditionally associate with our business. That would be one thing and then the other piece would be the language piece. Jeff: It's always surprising when I discover that the language that we use internally for our business doesn't match the language of the customer. An example would be we talk about binding covers all the time because we're in the world of binding. A lot of people they just talk about card stock. In the paper world, the card stock doesn't even exist. It's not a thing. People will talk about it. It's cover weight paper. Index weight paper. Card stock is like this sort of crafting term. Yet it's sort of taken on a vocabulary of its own in the world. Jeff: When people search for binding covers, often they'll use that word. That's always surprising to me as well. There's a whole list of those things where people basically they choose to use their own words to describe things. Now you're trying to figure out how do I technically be accurate about this product but really use their language? Because if you don't use their language, then you're not going to show up in search for this stuff and they're not going to feel comfortable with it. Stephanie: That's a really good reminder, especially with generational shifts that the new consumer might be using completely different language than what you're used to. How are you exploring what that language might be? I mean, especially a company that has been around since the thirties, how are they figuring out, oh, this is what they call it now, this is what the kids are saying these days? Jeff: Probably the easiest thing for us is to look through our search results and especially the no results found once because often it's those things. When people are typing in stuff in the search bar and nothing's popping up. You look at that and you're like oh... A smart merchandiser, someone who understands your products really well, they start to make those connections and they're like, oh, wait a second. That's what they mean. Obviously a lot of that like spelling mistakes and things like that. You can fix those in your search engine but when you start to look at it, you start to see sometimes patterns. That's one of the easiest ones. Jeff: The other two that are really helpful for us would be Google autosuggest. Just start typing things in Google and then figure out what Google thinks that you should add to the end of it. All of a sudden you realize, okay, maybe people are searching for maybe a slightly different side of things than we thought they were. Then the other one would be Amazon. Amazon, their product terms are awful. Yet they sell so much. Why? Because they tie into language. They have usually products that have all these different words in the titles that you would never imagine. Jeff: As you start to look at products that are really successful on the marketplaces, you can start to realize, okay, well maybe they're onto something there. They've managed to call out even the most important attributes of that product in a very search centric sort of model or they have really been able to hone in on maybe key words that we weren't thinking of when we've been building this out. Especially because often you start with whatever... A point of reference would be the manufacturer's title. It becomes quite difficult sometimes to sort of detach from that, but Amazon detaches automatically because they let people come up with their own titles for stuff. Jeff: Usually it's the sort of ecosystem that will change the title to try to optimize. Sometimes when you find really successful products that you're realizing, Oh, maybe people do care about that. Stephanie: I love that. That's really good tips to remember about, finding those keywords and how to discover them because yeah, I think even longterm key words would probably be really good for your industry. I'm thinking, how would I Google something like that? I would probably be like how to create a hard cover book for my presentation or something really long winded like that. It's a really good reminder about the keywords importance. Jeff: Then obviously you have your paid search stuff too. You can look and see in your paid search accounts, you can say, okay, what keywords are actually driving? If it was a broad or a modified broad match keyword, you're going to start to dig in and you can say, oh, it actually matched on this keyword and it drove a sale. Again, driving back and saying, okay, what am I driving sales on? It tends to be a really good place to start discovery as well. The only thing, the problem with that is that you might be so far off that you're missing the boat completely. That's where it takes a really good merchandisers to sort of nail that stuff down. Stephanie: I also think it was interesting earlier when you were talking about how to laminate without a laminator and thinking about selling something through saying, oh yeah, you don't need to buy through us. Here's how you do it because I'm sure a lot of people, like you said, are searching for stuff like that or how to fax without a fax machine. I know I've searched that quite a bit, but making fun of it and you might actually be able to convert someone who's like, Oh, I actually just do need a laminator to do this, but having a humorous video around that. Jeff: Yeah. As well as maybe they decide that they want to buy some cold laminating pouches. The idea is, if you can be really helpful in the long term, going back to that idea of video. We've done a lot of videos over the years. We understand that many, many, many times people use our videos post-purchase not pre-purchase. People are going to the video to figure out how does this thing that I already bought work. Well, that doesn't really help us but it does help us in the long term. Jeff: As you look at it and say, it's not going to win us the sale today, but it will win us brand awareness. It does potentially when you do supply sales. Because we're a very supply driven sort of space. If you think about it, if you buy a binding machine, you got to buy some supplies for it. Longterm, we want to have an awareness and be in front of customers so they understand who we are when it comes time to buy the supplies that they need. Stephanie: Just like you said, it's really important to continue to stay in front of that customer so they come to you to buy supplies and remember you guys. How do you go about doing that and keeping a customer retained? Because it seems like it would be easier with these legacy customers who are maybe in these year or three year long contracts. Now when you're moving towards Ecommerce and they can hop around really quickly, it seems like you wouldn't be able to retain customers as easily. So how do you go about staying in front of them? Jeff: I mean, there's a lot to that, the question. To give you maybe a general overview of our thoughts is a big part of our business and something that's really important to us. Especially on the E-com side of things, it really starts with delivering a really awesome experience upfront. So you need to be able to help them find what they need and then deliver it to them in a really reasonable timeframe or meet their deadline. All that kind of stuff. To have the product in stock and all of those kinds of pieces. That's actually harder said than done when you deal with a really large niche category. Jeff: That's the beginning piece of it. Once you've given them that positive experience, or if they've had a negative experience, you use your customer service to basically earn a customer for life. That's actually the motto of our customer service group. Earn a customer for life. As you look at this idea, you say, okay, well, we now have a shot at their business longterm. Now the challenge for us is, okay, what's the best way to reach them? The easiest way is email. We have a ton of automation in our emails. We send emails based upon what you've purchased with replenishment. We send life cycle campaigns based upon... Welcome to the store anniversaries campaigns, and then also best customer campaigns, win back campaigns and reactivation campaigns. Jeff: We have all these automations that go out. They're really helpful. We also have sales that go out on a weekly basis that keep people engaged and keep things front of mind for them. You combine all of that on the email side, but then you recognize that that maybe only gets you half the customers. The question becomes... Because there's a bunch that are opted out in the B2B space, it's really hard on deliverability to get into the inbox. More and more people are using advanced filtering programs to prevent spam from getting through to their employees. Jeff: As you look at that, you say, okay, well, email only takes you so far. So then what do you do? The real question is, back to that conversation we had earlier about lead scoring, how do you determine your best customers or your best potential customers and make sure that you get somebody to call them? To send them a personal email which are easier to get into their inbox or to find another way of touching them. For us right now, the two other ways of touching them that we're sort of exploring, one would be SMS and then another would be direct mail. We're kind of in the process of exploring a test on SMS. Jeff: I'm not too sure how we feel about it, honestly. We have to figure out how our customers feel about it, just from the standpoint of as you look at customers giving their personal cell phones for business purchases and getting text messages. But you think about it, that's a great way to get in front of people and stay in front of them as long as you're going to be super, highly relevant. Then the other piece of it that we do a little bit of would be on that retargeting side of things. If you don't know who that customer is exactly, or don't have their ability to email them, you can at least sort of [inaudible] do it, make sure you're sending or placing ads more frequently into their feeds on different platforms through retargeting. Stephanie: That makes sense. It seems from, especially in SMS perspective, it seems like the only angle you can go about is being helpful. Like oh, you probably are running out of supplies, order now. I don't know, you can get a discount or something. It seems like there's not too many ways for B2B companies to use texting without the customer being like, "Oh, I don't want to be thinking about work right now." Unless it's a trigger for them to be like, "Oh, I need to reorder this or else we're not going to have it on the day." Is that true or are you seeing other avenues? Jeff: Well, the first step would be to be helpful with order cycle. For instance, think about what Amazon has done with allowing you to get a text when the item is delivered. Which is a big problem for a bunch of our customers, especially in pandemic, but even outside of that. It might be delivered to a central desk or to the shipping and receiving area of their company like an alert. Alerts are a pretty good option for us to sort of get our toe in the water a little bit and to stay active. Then yes, something that's personalized. Jeff: Then also, what we're struggling with is what is the best time of day to do this? Probably don't want to send it to them in the middle of their evening. They're disconnected from work, but you also need to make sure that... It's got to be time adjusted for the time that they're in and they also really needs to be followed in their workday probably. Those are some of the things that we're sort of figuring out and testing right now and saying how is this going? Then what's also the most appropriate way to collect where people don't sort of get freaked out. Because it's one of those things, do you want to get text messages from your binding company? I don't know. You got to ask it in an appropriate way. Stephanie: Yeah. That's a really good reminder. All right. We have a couple minutes left and I want to jump into a quick lightning round brought to you by Salesforce Commerce Cloud. This is where I'm going to ask you a question and you have a minute or less to answer. Jeff, are you ready? Jeff: Okay. I'm ready. Stephanie: I'm going to start with the hard one first for you because I feel like you're in a game right now. I got to keep it going. What one thing will have the biggest impact on Ecommerce in the next year? Jeff: Well, I think obviously it's COVID. It's pushing people online in completely new ways. It's shifting customer expectations around a whole bunch of different things. It's ruined the Amazon two day expectation, which I don't mind, but it's also shifted the way that people shop, where they're shopping, how they're shopping, and even their mentality. I don't know that we even really totally understand how it's affected everybody yet because everybody's still sort of in this scrambling mode. But ultimately I think as this shakes out, it's going to change the landscape of how we market, but it's also going to change the landscape of how our customers interact with us. Stephanie: I like that. What one piece of advice would you give a new Ecommerce entrepreneur? Jeff: I would probably say stick with solving the customer's problems. I know that tends to be a B2B thing, but it's not really a B2B thing. If you think about it, I need the right sweater for me. Really be customer centric. That becomes really cliche and that's why I go to the idea of solving a problem. You got to think about what sort of value proposition are you offering to this customer that's unique, that is going to allow them to accomplish something that they wanted to accomplish when they came to your site. Jeff: I think by focusing and being really focused on the customer problem, I think you can build out really awesome experiences, and then that deep understanding of your customer will take you really far. Stephanie: That's a good one. What is your favorite day in the office? I'm trying to imagine what a binding company feels like. What's your favorite day in the office feel like? Jeff: I mean, most of my days are pretty full of meetings. A day without meetings would be an awesome day in the office. Stephanie: That's a lot of people. Jeff: I think so. In the world of the binding company, a day in the office doesn't look all that much different than a day in a normal office. It might be a little bit like an episode of the office. Stephanie: That's what I had in my mind honestly. Jeff: Yeah. It's like paper company. There is a little bit of aspects of that, but I mean, we're just like any other company. We're a retailer, we're a distributor. We deal with customers all day long. I would say the other thing, the best day in the office is the day that you have customers that love you and that are just heaping praises, especially on the customer service people and your salespeople. When you have customers who are just singing your praises, those are great days. Stephanie: Yep. That's awesome. I'm glad you mentioned the office and I didn't have to. If you were to have a podcast, what would it be about and who would your first guest be? Jeff: That's a tough one. If I were to have a podcast. I am super passionate about entrepreneurship. I'd probably do an entrepreneurship sort of a podcast about starting a business, growing a business, and the creativity that goes around that. If I could get anybody on the show, I would probably pick an entrepreneur. Maybe I pick the person from lemonade stand or one of those organizations that's really making a big impact on starting up entrepreneurs with kids. That's something that I really love. Stephanie: Yep. I like that. Brings back the memories of my parents make me [inaudible] my neighbor's yard for 25 cents which is well below market. Jeff: I think you could make at least 50 cents for that now. Stephanie: I think so too. All right Jeff, this was very interesting, such a good conversation. So many good tid bits that people can actually use from this interview. Where can people find out more about you and Spiral? Jeff: Sure. You can definitely visit one of our websites. We've got SpiralBinding.com. We have MyBinding.com and Binding101.com. You can find me on LinkedIn as well. Shoot me a message and ask me to connect and I'd love to meet you. Stephanie: Awesome. Thanks so much for joining Jeff. Jeff: You're welcome. Thank you.

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. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60. Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness. Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures. Nachi: So there must be guidelines for those recent post-op for flying - right? Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room. Nachi: Then why are people always getting sick after flying…? Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back. Nachi: Interesting. Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day. Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away. Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology. Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions. Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at. Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies. Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies. Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions. Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology. Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases. Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control. Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board. Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies. Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome. Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available. Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening? Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight. Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus. Jeff: For many ED providers, functioning as a consultant will be unfamiliar. Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school... Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act. Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation. Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.” Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard. Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution. Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services. Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in? Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly. Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert? Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable. Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here... Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate. Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference. Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble. Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort. Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight. Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it. Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections. Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls. Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights. Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets. Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol. Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events. Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases. Nachi: AEDs are required on all US-based flights. Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity. Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act. Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct. Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence. Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances. Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%. Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection. Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important. Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine. Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor. 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: 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.

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

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

Get your black hair dye and leather pants out! Then listen to the boys talk about how freaking awesome this 90's film is with our Crow (1994) VHS Movie Review. Quick FactsDirected by Alex Proyas (Dark City)Produced by Jeff Most, Edward R. Pressman and Grant HillWritten by David J. Schow and John ShirleyBased on The Crow by James O'Barr Starring Brandon Lee as Eric DravenRochelle Davis as SarahErnie Hudson as Sgt. AlbrechtMichael Wincott as Top DollarBai Ling as MycaSofia Shinas as Shelly WebsterAnna Levine as DarlaDavid Patrick Kelly as T-BirdAngel David as SkankLaurence Mason as Tin-TinMichael Massee as FunboyTony Todd as GrangeJon Polito as GideonBill Raymond as MickeyMarco Rodríguez as Torres Production company: Dimension FilmsDistributed by MiramaxRelease date: May 13, 1994Running time: 102 minutesBudget: $23 millionBox office: $50.7 million VHS Box description "Spectacular!" -Chicago Tribune"Thrilling!" -Los Angeles Daily News"Action-packed!" -WBAI Radio, New York"A Triumph!" -Playboy"Brandon Lee Is Sensational!" -Rolling Stone The Year's Most Talked-About Film! Catch the explosive, action-packed hit that thrilled moviegoers and dazzled critics everywhere! Brandon Lee (Rapid Fire) plays Eric Draven, a young rock guitarist, who, along with his fiancee, is brutally killed by a ruthless gang of criminals. Exactly one year after his death, Eric returns-watched over by a hypnotic crow-to seek revenge, battling the evil crime lord and his band of urban thugs, who must answer for their crimes. Loaded with intense, nonstop action and a hot #1 hit soundtrack, The Crow delivers exhilarating, fast-paced entertainment! Also included, the exclusive featurette of Brandon Lee's last on-camera interview including never-before-seen footage, conducted shortly before his untimely death! "The Best Movie of it's kind since the original Batman!" -Chicago Tribune Top 5 Box Office Results in May 19941 The Flintstones $130,531,208 2 Maverick $101,631,2723 The Crow $50,693,1294 Beverly Hills Cop III $42,614,9125 Crooklyn $13,642,861 How to find Analog Jones Discuss these movies and more on our Facebook page. You can also listen to us on iTunes, Podbean, and Youtube! Email us at analogjonestof@gmail.com with any comments or questions!

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

Welcome to the Real Estate Investing Mastery podcast. Today, we have people who've just completed an Implementation Workshop here to say a few words about the experience. First names only, of course. Jeff: Most important for me was learning how to set up the Mojo dialer, and how to hire/use a virtual assistant. Eric: After […]

Welcome to the Real Estate Investing Mastery podcast. Today, we have people who’ve just completed an Implementation Workshop here to say a few words about the experience. First names only, of course. Jeff: Most important for me was learning how to set up the Mojo dialer, and how to hire/use a virtual assistant. Eric: After […]

Welcome to the Real Estate Investing Mastery podcast. Today, we have people who’ve just completed an Implementation Workshop here to say a few words about the experience. First names only, of course. Jeff: Most important for me was learning how to set up the Mojo dialer, and how to hire/use a virtual assistant. Eric: After […]

West Hartford may not have the Hollywood sign, but it does have lights, cameras, and action going on inside what was once a Friendly's restaurant in the town's center. The movie being filmed is an action thriller called Pawn and has stars like Michael Chiklis, Forest Whitaker, Ray Liotta and Nikki Reed. A major reason the high profile film is being shot in Connecticut is because of the tax credits the state offers movie makers. LocalOnlineNews.TV was granted an exclusive interview with Pawn's producer Jeff Most to find out why they chose West Hartford as a shooting location. Pawn is scheduled to be released in 2013.