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Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for 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)

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

Job Insights #3: Mastering the Elephant in the Room - Disclosing a Disability in the Job Interview Process. Transcription Provided   Full Transcription Below Welcome to Episode 3 of  Job Insights with Serina Gilbert and Jef Thompson. We focus on Employment, Careers, enhancing opportunities and bringing you  the latest innovations from across the Vocational  Rehabilitation field to ensure your choices lead you down the career pathway that you want and succeed in gainful employment. From getting started with services, to assessments, Individual Plan for Employment (IPE) to gaining the skills to succeed and tools for success, Job Insights will be giving you tips and tricks to help your journey to employment and break down the barriers along the way. In this episode we take on the White Elephant in the Room, that is, the job interview room. With guest voices answering the question, “Do you disclose your disability during the job interview process, and if so, when do you disclose?” Hosts Serina Gilbert and Jeff Thompson take a good look at this Million Dollar question from all points of view and leave you with information that will better prepare you for your job interview process. There may not be one set way and being prepared for the job interview gives you an advantage that may help you land the career you want. Check out episode 3 of Job Insights and send us your feedback and topic suggestions by email. mailto:jobinsights@blindabilities.com   Follow the Job Insights team on twitter @JobInsightsVIP http://www.twitter.com/jobinsightsvip   Job Insights is part of the Blind Abilities network.   Thank you for listening. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free Blind Abilities App on the Google Play Store.   Full Transcription   [Music] Female voice: And most of the people that worked there did not know that I had any sort of vision impairment or anything like that, and at that time I was not comfortable walking around with my cane. Jeff: Job Insights, a podcast to help you carve out your career pathway and enhance the opportunities for gainful employment. Female voice: Because an interview is not just the employer figuring out if they want to hire you, it's you figuring out if you want to work for the employer as well. Jeff: To help you navigate the employment world and give you Job Insights and enhance the opportunities to choose the career you want. Selling yourself, you want to be the best box of cereal on the shelf because when people come down they're looking at all the colors all the things, what makes them pick a certain box? Is it the toy inside, is it the fancy colors? So you had to start selling yourself and be the one they pick. Female voice: If you have more of a obvious disability, you want to make sure that you kind of address that in a way that makes it so that they're not thinking about that, they're thinking about your skills, that's what their inner monologue isn't about you, it's about what they think that you can't do in their bias. Jeff: And you can find the Job Insights podcast on Blindabilities.com, part of the Blind Abilities network, with host Serina Gilbert and myself, Jeff Thompson. And you can contact us by email at Job Insights@BlindAbilities.com, leave us some feedback or suggest some topics that we cover. On Twitter at Job Insights VIP and check out the Job Insight support group on Facebook where you can learn, share, advise, and interact with the Job Insights community. [Music] Female voice: I didn't catch them off guard by showing up with a cane, and I found that that approach worked really well for me. [Music] Jeff: Learn about resources for training, education, and employment opportunities. Female voice: I think sighted people just like since video calls exist, they, that's what they use, so it's definitely becoming, it's going to be a type of interview than most people will have I think. Jeff: And now please welcome Serina Gilbert and Jeff Thompson with Job Insights. Hey Serina! Serina: Hey Jeff! Jeff: To disclose or not to disclose, that is the question I ask of thee. Serina: Have you been reading Shakespeare? Jeff: No, but I have been reading the Job Insights support group page. There's been a topic going on there about disclosure. Serina: Yeah it seems like a lot of people have some different opinions on, do I talk about my disability in the job interview, do I not? [Sound Effect] Female voice: I have a very disability in that I use a cane, and I can't make eye contact and so I find that usually, and this is the same thing that I did after the phone interview but before the in-person interview, I disclosed. [Sound Effect] Female voice: Do I talk about it when I'm doing my cover letter or my resume or not? [Sound Effect] Male voice: If you're applying for a position and it involves using some kind of accommodation, then it's probably wise to disclose it. [Sound Effect] Serina: And I really wanted to see if we could talk about that a little bit today get some different opinions. [Sound Effect] Female voice: If I need to than I do, if I don't need to I don't. [Sound Effect] Serina: Just get it all out there, I know this will be a pretty divisive topic, everyone has some pretty strong opinions on disability disclosure. We're here to offer you some tips on what might help you in the job interview process, when might be a good time to disclose and work to your advantage in a job interview, and maybe when might not be a great time to bring that up in a job interview. Jeff: And when to know the difference, that's um, I think the most important thing. Serina: Exactly. Jeff: Some of the topics that came up really shocked me like, I do my own accommodations a gentleman said, and that just made me cock my head and I had to think about that for a little bit, and yeah I get that, or someone says how dare you can you show up and shock them by showing up with a cane, you didn't tell them, and I'm thinking, like in some situations the resume does not have a spot for that, they may be able to dissect it out of the some of the positions you've held, or some of the companies who worked for, but I think mostly it's one of those situations that you're prepared for either way. Serina: Well and it's interesting that you brought up the I provide my own accommodations piece of the equation. I respect anyone who wants to step up and say here's what I need, I already have it, that's great, but in a lot of systems you can't install your own programs onto computers without having some significant permission. For example I work for a government agency, there's no way they're gonna give me an administrative password and all kinds of leeway to install any programs that I want because who knows what they could do to their network. Of course I know that JAWS is safe and I know that they know that JAWS is safe, but they still have to have some sort of system for managing the programs that are on their server and other network because what if you install a pirated piece of software then what, not saying that you would, most employers unless it's a real small company, it is their legal responsibility to provide you with that reasonable accommodation so why not take them up on it as opposed to using your hard-earned money to purchase those licenses and keep that up on somebody else's computer. Jeff: So having JAWS, having accommodations, and talking to them about accommodations that to, to read the screen, you can even have a person come in to do evaluation of what kind of software they're using, what kind of databases they're using, the see if you can gain access, and further down the line some scripts could even be made to help these specialized programs that they utilize just so you can overcome that hurdle, and it might be just a button that you have to get past. Serina: Exactly. Jeff: So there's some great services that are out there when you're trying to get a job, especially when you're into the job field, it seems like State Services has a whole arsenal of people that are help at that point, or if you're trying to retain a job too. Serina: That's a really good point, yes if you maybe already have a job, gosh I didn't even think about that Jeff, if you, if you already are working, I've seen that and quite a few of the support groups on Facebook, I'm working, I'm losing my vision, I don't think I can work anymore, and just remember that if you are having vision difficulties at work, you are still able to go apply for services at vocational rehabilitation and see what kinds of things they might be able to put place so that you can keep your job. I'd hate to see somebody that has 20 or 25 years in a career and you're just that close to retirement and feeling like you have to give up because your vision is changing with all the technology that's out there now, not saying it's gonna be easy, there's gonna be some learning curves for sure, but the sooner you start getting those services, the sooner you can get back to working in the job like you used to. Jeff: Yeah and that job retention it's a lot, I'm not gonna say it's a lot easier, but what it does is, you're gonna go into some specifics you know, you're just gonna do this to bridge this, to bridge that, to shore up what you're not able to do because it's obvious right away, rather than if you leave the job you go back home then you get to start from scratch like, I want to learn how to cook, I wanna, you know so it's interesting at different points when people are losing their vision, but when we're talking about disclosure, is that's a unique point too. I suppose because I've been blind for so long that to me I can live within my skin, and I think the difference is people who are trying to, especially high partials, or partials, they're either around blind people, there the sighted person around sighted people or they're the blind guy, or the blind person. Serina: Mm-hmm. Jeff: But at a job interview, there's a quandary there, do they use their cane or not use their cane and bump into things or do they bring their cane? Serina: You just brought up a really interesting point because I just thought back to when I was 19 and I started getting cane training from vocational rehabilitation, and at that time I was a cashier at a retail store, and most of the people that worked there did not know that I had any sort of vision impairment or anything like that, and at that time, I was not comfortable walking around with my cane. I'd rather bump into somebody then be seen as the blind girl. So at the age of 19 I would have absolutely said, no way I am not disclosing my disability, I can do it just as well as anyone else. I will just work twice as hard, and struggle at times, but now gosh, 20 years later ish, I think totally differently I, I could never personally see an instance where I would not want to disclose that because I don't want it to be the elephant in the room, when I'm being interviewed. Jeff: Mm-hmm. [Sound Effect] Rob Hobson: It's really up to the individual, some people like to not say a thing, show up to the interview, surprise I'm blind, you know, granted they don't say that. I think to the interviewer that, that's a surprise, but if you want to go that route, that's totally fine it's entirely up to you. But I want you to think about something when you go in for that interview, blindness is that, the white elephant in the room, if you don't address it, you're left to whatever conceptions they have a blindness, positive or negative, but if you address it as in a positive way, you bring up the fact that you are blind, and that you utilize accessible technology via you know whether it's JAWS or NVDA, or a system access, whatever it is you use, explain to that employer why you're the best candidate for the job. The long answer is, it's up to the individual, but if you don't address the fact that you're blind, I think it puts you at a disadvantage. Jeff: And that was Rob Hobson, he's the director of programs at Blind Incorporated in Minnesota. [Sound Effect] Jeff: And that's what it is, it's that the elephant in the room, and if you don't squash that, they're gonna paint their own picture as big as a an elephant any way they want to. Serina: Well and the reality is is that every employer knows that they can't come out and say, what's your disability, they can ask, do you require any reasonable accommodations to perform the essential duties of this job, which is a roundabout way of still figuring it out obviously. But if you're coming to an interview and you're using a service animal, or you have a cane, it's right out there and then they're just wondering, well how on earth is she going to be able to do this, or how is he going to be able to spellcheck documents for me, or access the computer? Because the technology that we use is not mainstream, most people don't even understand what a screen reader is unless they know somebody who has a visual impairment. Jeff: Mm-hmm, yeah and that's the point where you have the opportunity to educate them and sell yourself with the skills that you do have. Serina: Exactly, one of the other panelists did bring up a really good point. If it's a phone interview, that's totally different, they don't see you, they have no clue what you look like, what your abilities and capabilities are, and then what you're selling to them. I don't think I would mention it in that interview type of setting, what about you Jeff? Jeff: No I really don't think so, I think the phone call is a situation where they're just starting to get a good feel of how you, you know your social skills, they want to find out if you're a good fit for the team, for the company. Serina: Correct, because we talked about this a little bit on our very first podcast, if you got the interview then they have already determined that you're qualified for the position, they're just trying to see if you're a good fit for the office but, whether that be the culture, or some more specific questions that they weren't able to flush out in the application process, by not discussing your disability when you have a visible disability, you're almost causing the employers to only focus on the fact that you just walked in with a service dog, or with your cane, and is human as people want to be, and is empathetic and understanding as they claim to be, that's still going to be in the forefront of their mind especially if they're not familiar with your disability. Jeff: That's where Daysha the employment specialist brought up a very good point about where you're just talking about and she called it the internal monologue that the hiring person will be creating. [Sound Effect] Daysha: When you do talk to somebody, especially if it's an interview, you're gonna get that tell me about yourself, you could even get that when you just meet an employer at a job fair or an internship fair, tell me about yourself. You want to make sure especially if you have more of a obvious disability, you want to make sure that you kind of address that in a way that makes it so that they're not thinking about that, they're thinking about your skills. A lot of people make the mistake of never seeing anything and then an employer, the whole time that they're talking is thinking, well because they don't have any experience with vision loss, so they're thinking to themselves, I don't know that I could do that if I couldn't see right, I'm not sure that they're gonna be able to do that, that's what, their inner monologue isn't about you, it's about what they think that you can't do and their bias. Tell how you do things, go into it with confidence, know what your skills are ahead of time, know what you have to offer an employer, and just go into it that way. [Sound effect] Serina: Exactly they start putting those doubts in their mind. I don't know if they'll be able to do this, what about safety concerns? That's a really big one, is my workers compensation insurance going to go up because I have this individual in my office who's presumably, whether correct or incorrect, going to be causing more workplace incidents or accidents. Which we all know if you've gotten your orientation and mobility training in your personal adjustment training, your always more safe than the people who are sighted in the office, because you're not walking around on your cell phone or distracted. [Laughter] Jeff: We'll have to put in ramps and handrails, we'll have to label everything and yeah, but you can control that, and I think at that point, you know you're coming in with a cane and you know they don't know it yet, so that's your opportunity right there, that's your opportunity to call out the white elephant in the room in your favor. You can address it and you can tell them exactly like we said, selling yourself, you want to be the best box of cereal on the shelf, because when people come down, they're looking at all the colors, all the things, what makes them pick a certain box? Is it the toy inside, is it the fancy colors? So you have to start selling yourself and be the one they pick. Serina: It's interesting that you mentioned when you come to the interview, let's say with your cane or your service animal, I have seen situations where individuals do have a visual impairment that warrants the use of a cane and they opt to not bring that to the job interview, and I have seen that cause some problems, because when you don't have your cane or your service animal that could create some super awkward situations when you're trying to interview with the employer. As an example, the employer comes out to the lobby to get you, and maybe your vision is not adjusted or whatever the case may be to that particular office environment, and you're walking not so steady, or unsure about yourself, just think of the assumptions that they're putting in their mind now with the individual that's interviewing for the job, but not walking appropriately in their office, or not making eye contact, or not quite getting the handshake. Jeff: Mm-hmm, yeah and that's very important because myself, I have no central vision, and I can pick up some peripheral stuff, but in an interview you're probably trying to make the best eye contact you can, and I was just in an interview, this was a podcast interview and I told the person right off the get-go, don't think I'm looking over your shoulder or something behind you because that's how I sometimes pick things up by looking away from what I'm really looking at, so I actually made them feel more comfortable than them trying to talk during the interview wondering, what's behind me he keeps looking at, or something like that. Serina: Exactly, yeah. Jeff: In reality I, whatever I'm looking at I can't see anyways, so you can control the situation. They're going to start working this white elephant up in the room, they're gonna start, and not even hearing what you're talking about, all the stuff you're talking about, so you have to get control of the conversation a little bit and that's where you can start saying that, how you overcome doing job details that they want like word document that you use because you use JAWS, or how you can use other type of apparatuses or tools for success that get you to the point where you can compete against anybody that they hire. [Sound Effect] Miranda: I say no because I feel like with as much misunderstanding as there is in the world with with blindness, it's easy for a employer or potential employer to look at your resume and see that you're blind and see all these other resumes that he's got to go through that are just as educated, just as qualified as you are, and to simply just let that one go, like alright, I'm not gonna deal with that. I mean because you're you're talking about them having to deal with ADA and all this, all that other kind of stuff, walk in there confident and stuff, don't disclose before you go in, and just be like, hey this is what I can offer your company. If you made it in there, if they invited you in then that means you're qualified and you should have a shot at it just as everybody else. Jeff: You're listening to the voice of Miranda Brandenburg, she's a certified personal trainer and nutritional specialist. Miranda: The vast majority of people out there have never dealt with a blind person or encountered someone, especially one that is out there making waves, that's out there leading the charge, that's out there willing to work and get in there and travel and do this and do that and get out on the mat and fight and compete with sighted peers on every single level that they can. [Sound Effect] Serina: And it doesn't have to be the first thing you talk about you know, it can be something that, because I've never been an interview that didn't say at the end, do you have any other information like to offer me, or do you have any questions for me, I don't, what about you Jeff? I've never not been asked that? Jeff: Every time and have that question, because they want to know something, so I suggest before you going into an interview, go online, read their mission statement, see what company they are, see what they're all about, what, what's their key words, and that's something that you might want to integrate into your dialogue with them, and then when they come with that question, ask that question, like do you have any questions about my ability to do this job? Serina: And the way that I've approached it, I've only had to do it once, because one was I was applying for a County job at a local Workforce Center, and the second interview was using a white cane, was at the division of vocational rehabilitation. So it could not be more of a comfortable environment. I didn't even have to address it there, but the first one I did come in, I had my white cane, towards the end they said, do you have any more information you'd like to share with me? And I said well, you know, you obviously know I have a visual impairment, I just wanted to give you some information on the technology that I use in order to get things done, and I had gone as far as to print out some real short tip sheets on, at that time I was using a portable CCTV, and JAWS, so that they knew I had already thought about the types of things that I might need on the job and was already skilled in that, so that they didn't have to worry about, okay, obviously I'm gonna have to train her on our procedures, but is she also going to have to get training on her technology needs. Jeff: Mm-hmm, and that's a good point to come in there and let them know how you're gonna access the material that they have. Serina: Mm-hmm, now I have seen some questions in our support group about, do I disclose in the application process? A lot of applications are automated and they, some of them do ask if you have a disability. So I wanted to talk a little bit about that because, yes they might be asking if you have a disability, but if, unless they're breaking the law, that information is not to be passed on to the hiring manager or the individual that's reviewing your application. Typically when they're asking if you have a disability or require reasonable accommodation, that information is used for one of two things. The first would be that there is a program called Work Opportunity Tax Credit which allows employers to have taxes reimbursed to them to offset hiring expenses and things like that for hiring individuals in a variety of situations including those that have a disability, as well as those that are on public assistance, or they're using it because they know that they have some sort of testing that all the applicants have to do, and they really truly are trying to reasonably accommodate anybody that might need those accommodations. So I wouldn't hesitate to answer that personally because that could put you in an awkward situation down the road should you have to take, for example if you're applying at a call center, should you have to take one of their tests and all of a sudden you're asking for an accommodation when on the application you said that you don't need accommodations or don't have a disability. Jeff: And the same thing in Minnesota our Governor passed two years ago, he passed the proclamation that 7% of all employees in the state jobs, they'll hire people with disabilities to fill that 7% goal that they want to have, and so in some applications, some situations, there is a checkbox for that, and that way companies that do want to hire people can have that choice too. Serina: And that brings up another good point, the federal government also has a mandate that they have to hire a certain percentage of individuals with disabilities, and in fact, if anyone has been through that federal hiring process, it's a nightmare to say the least. If you do not check that you have a disability, then you're not going to be considered in any of the priority categories which means that your application might never even get looked at for open position. Jeff: Yeah it's a tough area and a lot of us, like I said on the last podcast, a lot of us aren't fully up on everything that there is to know about blindness when you probably, if you weren't born blind, or you just became blind, there's a lot to learn and there's lots of people that are offering suggestions and no one's really wrong, but I think the best fit is the best fit that you feel most comfortable with because if you're uncomfortable they'll know you're uncomfortable with it so, that's why in Minnesota here at the state agency, they do tutoring on job interviews, mock interviews, where you do get the situation that you know, mister mister boss might ask questions or make you feel awkward in a sense just so you can understand that every interview that you go to, you're gonna get a different person that has different preconceived ideas and it's gonna be in a different situation each time. So if you have an opportunity to try a mock interview, that'd be really great experience. Serina: Well and frankly I remember reading an article, I think it was last year, people are actually scared of blindness, they would rather have cancer than be diagnosed with being blind or visually impaired. So imagine that fear then being put into the situation of, oh my gosh how could I possibly hire somebody that has this visual impairment? If you don't address how you do things in the workplace. Jeff: Mm-hmm that's a great point, another great point is to remember they want to hire someone who can get the job done. Bottom line, get the job done. Susan Robinson, an entrepreneur out in New York and a TEDx speaker, and visually impaired by the way, she told me that she has never terminated a person because they were sighted. Serina: Hmm, that's an interesting way to put that. Jeff: Mm-hmm, she has a job that she needs to get done, she wants to hire the person that could come in and do that job, that's it. Serina: Wow, look at you getting all philosophical over there! [Laughter] [Sound Effect] Female voice: To me it was no different than anyone else doing the same thing with the exception of letting people know during an interview process what I might need from them. So again it was the same sort of self-advocacy to use your wonderful term as I did in college, so in an interview process, the first interviews is sort of getting to know each other, do I think I like working for this person? Because an interview is not just the employer figuring out if they want to hire you, it's you figuring out if you want to work for the employer as well. Once we got to maybe a level 2 or level 3 conversation in the interview process, at that point when it seemed to be a little bit more concrete that the position possibly could be mine, I would disclose and I would say, I just want to let you know I have a visual impairment, it may not be obvious to you, but what that means is I'm gonna bring everything that we've already talked about, my, all of the skills and characteristics that we've discussed, but I am going to need a large monitor for my computer so that I can see things you know enlarged a little bit, and generally people were very receptive to that because again I'm letting them know which is what every potential employer wants to know, can you do the job, are you willing to do the job, and are you going to be a good fit? [Sound Effect] Jeff: Serina, when we had our conversation with Cindy Bennett, a researcher out in Washington and a former intern at Microsoft, she mentioned something that we hadn't even considered, and that was, an interview via videoconference. [Sound Effect] Cindy: I think if I had a video interview I would probably disclose, but I would frame it something like, I'm actually blind so, I might be like, hey does the camera look okay, okay cool, like just like that, just really quick. I do practice if I do a video interview, I always like first of all clean my apartment and look nice. [Laughter] Second of all, I set up my computer on a table in front of my couch and call someone I know, like I video call someone I know and they tell me okay this is good. I found that just like a quick little thing at the beginning of the video interview, I'm like, oh by the way I'm blind, I just wanna make sure that you can see me okay in the camera. If it's an old-fashioned audio phone interview, then usually the person emails me and says we'd like to invite you for an in-person interview and I say thank you and confirm the dates and say, oh just for your information, I'm blind, here's what I need. Jeff: Were you excited when we asked for a podcast that you didn't have to clean your house? [Laughter] Cindy: Yeah [Laughter mixed with inaudible talking] I don't want to do a video call ........ I think they are important things to think about, like I honestly with a lot of my colleagues now that I'm comfortable with them, I'm just like, can we just do audio because then I can just set my phone down beside me and we can go on with our business, but I think sighted people just like, since video calls exist, they, that's what they use. So it's definitely becoming, it's going to be a type of interview that most people will have I think. Serina: I honestly didn't even think about how the video interview, how that would be impacted by the visual impairment, so I'm glad you brought that up because I haven't had an interview for a job since 2010 and it was definitely not when people were doing video interviews or anything like that, so that's definitely something to think about. [Sound Effect] Jeff: It's really great that so many people came on board and shared their experiences, the way they handle disclosing a disability during an interview and the people leaving comments on Job Insights support group page on Facebook. And to sum it up, here's Rachel Hastings, she just got done running the marathon, the Boston Marathon and she's a music therapist. [Sound Effect] Rachel: I've done it both ways, so I've done it one time I didn't tell them that I was blind until I got there and I think it kind of caught him off guard. I mean part of me is like deal with it, but the other part of me is like, well you know, there's no harm in telling them over the phone. After they invite you to an interview, and so because I kind of felt like I made it awkward, so the next time I was first offered a phone interview and I told them over the phone, I'm like, by the way I want to let you guys know that I'm legally blind, but I'm very independent and that, that was after they invited me for an in-person interview. So it's like there was no way they could turn me down but yet I didn't catch them off-guard by showing up with a cane in person, and I found that that approach worked really well for me. [Sound Effect] Jeff: So Serina, next week we're gonna be talking about some apps. Apps for the workplace, apps for productivity, apps for a school. Serina: Yep, I know that I have my favorites. Jeff: Hmm, you gonna save them, you're gonna make us wonder till next week aren't you? Serina: You guys will have to wonder till next week. Jeff: The cliffhanger strikes again. [Laughter] Serina: So I'd like to thank everyone for listening to our show today. As always if you have any questions or topics that you'd like us to follow, you can give us a message on Twitter, that's at Job Insights VIP, or on our Facebook page which is Job Insights, and we also have a brand new job insight support group on Facebook, just search Job Insights support group, see you next time. [Music] Jeff: Thank You Chee Chau for your beautiful music, that's lcheechau on Twitter. We really hope you enjoyed this podcast, thanks for listening, and until next time bye-bye! [Music] [Multiple Voices] When we share what we see through each other's eyes, we can then begin to bridge the gap between the limited expectations and reality of blind abilities. Jeff: For more podcasts with the blindness perspective check us out on the web at www.blindabilities.com, on Twitter at Blind Abilities, download our app from the app store, Blind Abilities, that is two words, or send us an email at info@blindabilities.com. Thanks for listening.