Podcast appearances and mentions of jeff welcome

Today on the podcast we have Jaco and Leslie Theron, two ministers in South Africa serving the poor and marginalized people in the bush. You might already be asking, what do South African missionaries have to do with White Collar justice? Well, I urge you to watch or listen to this episode in order to find out. Leslie was my classmate at Union Theological Seminary about a decade ago, we've stayed Facebook friends ever since. Last summer, at the start of the pandemic, my wife Lynn and I were in the backyard most weekends and listened to Jaco and Leslie preach on Facebook Live. What we heard and learned changed us forever and taught me huge lessons in identity and oppression - helpful to white collar families and all people on the margins, including myself. So coming up, Jaco and Leslie Theron. From South Africa. On White Collar Week. I hope you will join us. - Jeff ______________________ Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community. If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on… Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit. Blessings, לשלום Jeff Rev. Jeff Grant, J.D., M.Div. (he, him, his) Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & Nationwide Co-host, The Criminal Justice Insider Podcast Host, White Collar Week Mailing: P.O. Box 1, Woodbury, CT 06798 Website: prisonist.org Email: jgrant@prisonist.org Office: 203-405-6249 Donations (501c3): bit.ly/donate35T9kMZ Not a prison coach, not a prison consultant.

Today on the podcast we have Seth Williams. In a two-part interview, Seth describes his fall from grace from being elected the first African-American District Attorney of Philadelphia, America's 5th largest city, to being tried for corruption charges, to becoming a Federal inmate serving 5 months of his 60-month sentence in solitary confinement, to his new life of faith and service. A member of our White Collar Support Group that meets on Monday evenings, Seth goes into stunning detail about his poor choices, prosecution, prison experience and his lessons learned. So, coming up. Seth Williams. Former Philadelphia D.A. On White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast we have Seth Williams. In a two-part interview, Seth describes his fall from grace from being elected the first African-American District Attorney of Philadelphia, America's 5th largest city, to being tried for corruption charges, to becoming a Federal inmate serving 5 months of his 60-month sentence in solitary confinement, to his new life of faith and service. A member of our White Collar Support Group that meets on Monday evenings, Seth goes into stunning detail about his poor choices, prosecution, prison experience and his lessons learned. So, coming up. Seth Williams. Former Philadelphia D.A. On White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast we have my dear friend, Babz Rawls Ivy. Many of you know Babz as she is my co-host on our radio show and podcast, Criminal Justice Insider. We are in our fourth season of Criminal Justice Insider, still the only regularly scheduled criminal justice radio program in Connecticut, although we have many national justice-related guests, as well.Trigger alert: in this episode, we go deep into Babz's story of childhood abuse and trafficking. We also discuss Babz's life since, from attending Barber-Scotia College, a historically Black college in the South, voter registration with Andrew Young and Rev. Jesse Jackson, earning a Master of Public Administration at Baruch College in New York City, rape crisis counseling, and then as an Alderman in New Haven, where she ran afoul with the law. After serving time in Danbury Federal Prison, Babz went on to be lifted up and serve as Editor of the Inner City Newspaper in New Haven, radio show host, and board member of many arts and justice non-profits in New Haven. So coming up, Babz Rawls Ivy on White Collar Week. We hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast, we have Hannah Smolinski. Hannah is a CPA and founder of Clara CFO Group, a virtual CFO and consulting services firm providing small businesses with financial clarity as they grow.  Her experience for one of the world's largest accounting firms inspired her to bring that level of financial expertise to the small business community through financial strategy, best practices, and knowledge to realize their missions.Hannah is also a Senior Advisor to Upside Financial and its PPP forgiveness product, PPP Advisor Pro.This episode is chock full of important and topical financial information for small businesses and entrepreneurs, up to the minute details about PPP, PPP2, and EIDL loans, and so much more.So coming up, Hannah Smolinski, the Virtual CFO, on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast we have two of my favorite people, Glenn Martin & Richard Bronson, talking about how they each reinvented themselves after prison. They are both incredibly generous and reveal their struggles, disappointments, and frailties as well as their successes and service in helping others.Glenn talks about his journey from armed robbery to prison, to nonprofit executive, to founding Just Leadership USA, to entrepreneur, executive coach, and investor in Gem Trainers and Gem Real Estate. Richard discusses his Wall Street life, including at Straton Oakmont (made famous in the movie "The Wolf of Wall Street"), prison, and then founding two companies to lift up returning citizens, 70millionjobs.com and his latest, Commissary Club.So coming up, Glenn Martin & Richard Bronson: Reinventing Yourself on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

On the podcast today, we have Richard Lee. Richard is best known for having been a trader at Steve Cohen’s hedge fund, SAC Capital, and for having insider trading charges against him dismissed after a 7 year fight to clear his name. Richard initially pleaded guilty to insider trading charges in 2013, and upon discovery of new evidence in 2017, he moved to withdraw his original plea. On June 21, 2019, a federal court judge for the Southern District of New York granted Richard’s motion to vacate his guilty plea, and then on Nov 27, 2019, federal prosecutors dismissed all charges against him. I first met Richard in 2013, soon after he first pleaded guilty. We’ve been friends and have worked together closely ever since. On the podcast today, Richard and I discuss the entire story that led to his incredible outcome. So coming up, Richard Lee. Insider trading charges dismissed, on white collar week. I hope you’ll join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Many of our friends and colleagues in the white collar justice community tell me that they are writing books about their experiences or that someone should make a movie about them. Even me!So I contacted a few professionals I know in the movie and television production business and asked them what it takes to actually get the attention of a movie or TV series producer or director. And each of them was happy to come on the podcast to discuss it.We are calling this episode "Is Your Life a Movie?" Joining us are Lydia B. Smith, Bethany Jones, and Will Nix, three movie and television producers who actually make justice-related films or TV shows. And they each provided contact information for you to get in touch with them. So coming up, "Is Your Life a Movie? The Producers" on White Collar Week. I hope you will join us.- Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast, we have Vanessa Osage, one of the bravest and most intrepid people I have ever met. Vanessa had dedicated her life to breaking down the barriers of stigma and shame, and helping others to find a new order of loving accountability and restorative justice. We are calling this episode "Truth Heals: Systemic Abuse & Institutional Reform." In it, Vanessa tells her story of reporting sexual abuse at one of our country's elite boarding schools: retribution, coverup, engaging and then abandoning the legal system, attention in some of the nation's most respected newspapers and media, starting a non-profit to serve others going through these kinds of issues, and writing her incredible memoir, "Can't Stop the Sunrise: Adventures in Healing, Confronting Corruption, & the Journey to Institutional Reform."Joining us as co-host is Chloe Coppola, an advocate with us at Progressive Prison Ministries, who shares the story of her sexual abuse and institutional response while she was a student at her own prep school.Two courageous women telling their stories in intimate and powerful ways. So coming up, Truth Heals on White Collar Week. I hope you will join us.- Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

Today on the podcast, we have Bridgeport Mayor Joseph Ganim. After five terms as the mayor of the largest city in the state of Connecticut from 1991 to 2003, Joe was brought down in a corruption scandal for which he served six years in a federal prison. After his release from prison, in 2015 Joe ran again for mayor of Bridgeport and he was reelected. He is currently serving his seventh term as mayor.What I find most fascinating about Joe is his resilience and resourcefulness - his willingness to take risks and subject himself to public scrutiny after all he'd been through. Certainly, his story is a lesson to other people convicted of felonies that life is not over once you go to prison.Full disclosure: In 2016 and 2017, I served as Co-Chairperson of the Advisory Board to the City of Bridgeport Mayor's Initiative on Reentry Affairs.So coming up, Mayor Joseph Ganim on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit. Blessings, לשלוםJeff Rev. Jeff Grant, J.D., M.Div.(he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.org Office: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ Not a prison coach, not a prison consultant.

Today's podcast is about mental health and the crushing stress and depression that professionals sometimes experience that can induce suicidal ideations, suicide attempts, suicide itself, the pain and anguish caused to family and others, and how one can find relief and hope instead of pain, suffering, and tragedy. My guests today are Rev. Bob Flanagan, who has written, spoken, and preached about his own mental health issues. And Meredith Atwood, a former lawyer and now author and life coach, who is candid about her suicide attempt, sobriety after drug and alcohol addiction, and finding her way back through triathlons and weightlifting. And Elizabeth Kelley, a lawyer who specializes in representing defendants with mental disabilities all over the country, and in attorney wellness so that they don't burn out and cause harm to themselves, their families, and their clients.A warning: this is a very difficult conversation in which we all talk about our personal relationships with depression and suicide, a much-needed discussion in these times of community and personal trauma. So, coming up: A Brave Talk About Suicide on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…Our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

White Collar Week with Jeff Grant. It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 14: Recovery & Neighborhood with Tom ScottToday on the podcast, we have one of my closest friends, Tom Scott. You might know Tom as one of the "two Toms" who co-founded Nantucket Nectars. Or as the co-founder and chairman of The Nantucket Project, a thought and ideas festival each fall on the island of Nantucket, Massachusetts. Or as chairman at The Neighborhood Project that brings films about what matters most to discussion groups in people's homes all over the country and the world.But I know Tom differently, as my close confidant in drug and alcohol recovery in our home group in Greenwich, Connecticut. Tom and I both credit recovery with saving our lives, and with being the inspiration for Tom's project about the power of neighborhood and my project bringing justice-impacted people out of isolation and into community. This episode explores this, and the depth of our relationship Tom and I forged to find the light from the darkest times of our lives.So coming up, Recovery & Neighborhood with Tom Scott, on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

White Collar Week with Jeff Grant. It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 13: Everything but Bridgegate with Bill BaroniToday on the podcast, we have as our guest, Bill Baroni – or as they called him in federal prison, Billy Bridgegate. Bill was arrested, tried, and found guilty and served time for his role in the infamous Bridgegate corruption scandal that destroyed the presidential aspirations of former New Jersey governor, Chris Christie. Bill's conviction was overturned by the U.S. Supreme Court and today he is felony-free and talks with us about his journey.We are calling this episode "Everything but Bridgegate" because Bill can't discuss the nuts and bolts of the scandal due to pending legal matters. But what Bill does share with us is an amazing story of power, abuse of power, ambition, navigation of the criminal justice system as it applies to people prosecuted for white collar crimes, and ultimate vindication.So coming up, Bill Baroni on White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant.

White Collar Week with Jeff Grant. It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 11: The Blank Canvas with Guest Craig StanlandLink: https://prisonist.org/white-collar-week-with-jeff-grant-podcast-ep-11-the-blank-canvas-with-guest-craig-stanland/Today on the podcast, we have Craig Stanland. Not only does Craig have a great TedTalk out there, and a new book to be published next year, but he is one of my very first ministees. It's hard to believe that he first contacted me in 2013 after he was charged with fraud. He's been a good friend and colleague ever since, and is a regular member of our online White Collar Support Group that meets on Monday evenings.Craig actually led the discussion on the very first episode of White Collar Week, where we had sixteen of our support group members tell their stories. You can find the link to that episode here: https://prisonist.org/white-collar-week-with-jeff-grant-podcast-episode-01-16-free-from-prison-an-evening-with-our-white-collar-support-group/So, coming up. Craig Stanland. On White Collar Week. I hope you will join us.  - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZNot a prison coach, not a prison consultant. 

White Collar Week with Jeff Grant, A Podcast Serving the White Collar Justice Community. Limited 10 Show Run: Summer 2020It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 08: The Academics, with Guests: Cathryn Lavery, Jessica Henry, Jay Kennedy & Erin HarbinsonToday on the podcast we have four criminal justice professors at four different universities around the country. From the University of Minnesota, we have Erin Harbinson. From Montclair State, we have Jessica Henry. Joining us from Michigan State is Jay Kennedy. And from Pace University, we have my friend Cathryn Lavery.Our guests are on the forefront of reimagining our criminal justice system at a critical time in our nation's history - when a pandemic, social unrest, a Presidential election and the media all call for rapid responses to very complicated issues. Issues that each have dedicated their life's work to researching and teaching.I was most impressed with the raw humanity in this episode, and how much all of our guests really care about people in the most difficult circumstances we could imagine.So, coming up - The Academics. On White Collar Week. I hop you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ

White Collar Week with Jeff Grant, A Podcast Serving the White Collar Justice Community. Limited 10 Show Run: Summer 2020It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 07: White Collar Wives, with Guests: Lynn Springer, Cassie Monaco & Julie Bennett. Special Guest: Skylar CluettToday on the podcast we have three women from very different parts of the country - Georgia, Montana & Connecticut - who all have one big thing in common: each had a husband who has served time, or is still serving time, in a Federal prison for a white collar crime.In so many instances, families are destroyed by the actions of a partner that leads to divorce, estrangement from children, financial devastation - and untold resentment, suffering, embarrassment and shame. And certainly, our guests have all gone through, and still go through, much of this. As Cassie says on the podcast, "it's a life sentence." All let it rip with the poignant and painful truth.Yet, each of our guests have decided to stay with their husbands, and forge from the ashes new family lives that are perhaps better than before. And all are available to speak to other spouses and family members going through these issues. Indeed, it becomes clear on the podcast that families with white collar justice issues don't have to suffer in isolation, and can benefit from coming into community.We are all bonded in our brokenness.Here's a teaser: one of the women on the podcast is my wife and co-founder, Lynn Springer (and, my step-daughter Skylar Cluett makes a guest appearance too)!Four fascinating stories of four courageous women in conversation. Coming up, White Collar Wives. On White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ 

White Collar Week with Jeff Grant, A Podcast Serving the White Collar Justice Community. Limited 10 Show Run: Summer 2020It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 06: Madoff Talks, with Guest: Jim Campbell Today on the podcast we have Jim Campbell, a radio host and journalist based in Greenwich, Connecticut, who hosts a nationally syndicated business affairs show, Business Talk with Jim Campbell. He also hosts another show, Forensic Talk, that dives into the world of financial crimes. It's probably not surprising that Jim and I are friends, and that he has interviewed me on both of his shows. Today we turn the tables and Jim the interviewer becomes Jim the guest, as we talk about his upcoming book, Madoff Talks: Uncovering the Untold Story Behind the Most Notorious Ponzi Scheme in History. Jim's book will be published next year (McGraw Hill). He is now putting the finishing touches on his multi-year dialogue with Bernie Madoff in prison, Bernie's wife Ruth Madoff, and Bernie's late son Andrew Madoff, as well as government investigators, lawyers, witnesses, and most importantly, the victims. While Jim has culled over 400 pages of actual emails with Bernie Madoff - and presents Madoff's words verbatim - he never accepts any of it at face value. Jim investigates the truth behind the man, the family, the fraud, and the systemic breakdown of the SEC, big banks, and every watchdog that had the obligation and opportunity to stop the fraud before more people got hurt. And failed. The Bernie Madoff story was, and remains, one of the biggest tales of grandiosity and greed that Wall Street has ever known, and certainly the largest Ponzi scheme in history. And we have an inside, up-close look on today's podcast. So, coming up, Madoff Talks, with our guest Jim Campbell. On White Collar Week. I hope you will join us. - Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community. If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on… In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit. Blessings, לשלום Jeff Rev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ

White Collar Week with Jeff Grant, A Podcast Serving the White Collar Justice Community. Limited 10 Show Run: Summer 2020It's the Isolation that Destroys Us. The Solution is in Community.____________Podcast Ep. 05: A Family Affair. Guests: Jacqueline Polverari and Her Daughters, Alexa & Maria Today on the podcast we have Jacqueline Polverari, a mom who served time in a Federal Prison for a white collar crime, and her two daughters, Maria and Alexa. It is an intimate look inside how crime and prison ravage families, and the steps needed to heal and put families back together. As far as I know, this type of conversation has never before been recorded for the public. There is a lot of joy and laughter – and sadness and tears. Real stuff in the life of this family, and of every family going through difficult issues. Full disclosure, this is no ordinary family. Jacquie is a member of our White Collar Support Group that meets online on Monday evenings who has founded her own organization, Evolution Reentry in Branford, CT, supporting women who have been prosecuted for white collar crimes. Both of her daughters (and her husband Dave and son Thomas too!) give of themselves freely to regularly support the families of people with white collar justice issues. I am sure you will relate to and identify with so much in this podcast, regardless of what kinds of problems you and your family might be going through. So, coming up – the Polveraris. A Family Affair. On White Collar Week. I hope you will join us. – Jeff______________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community. If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on… In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit. Blessings, לשלום Jeff Rev. Jeff Grant, J.D., M.Div. (he, him, his) Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideCo-host, The Criminal Justice Insider PodcastHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ not a prison coach, not a prison consultant

White Collar Week with Jeff GrantA Podcast Serving the White Collar Justice CommunityLimited 10-Episode Run: Summer 2020It’s the Isolation that Destroys Us. The Solution is in Community._______________________Podcast Ep. 04: One-on-One with Tipper X: Tom HardinToday on the podcast we have Tom Hardin, best known in the financial and legal worlds as “Tipper-X”.Tom previously spent much of his career as a hedge fund stock analyst. In 2008, as part of a cooperation agreement with the Department of Justice, Tom assisted the U.S. government in understanding how insider trading occurred in the investment management industry. Tom became one of the most prolific informants in securities fraud history, helping to build over 20 of the 80+ individual criminal cases in “Operation Perfect Hedge,” a Wall Street house cleaning campaign that morphed into the largest insider trading investigation of a generation.Tom’s a fascinating guy – he goes into his personal history and family, much deeper than he does in his corporate presentations, He’s a member of our White Collar Support Group that meets online on Monday evenings, so we know his story well. In this podcast, I think you will learn a lot about Tom – and maybe something about yourself too?So, coming up – Tom Hardin, Tipper-X.I hope you will join us. – Jeff____________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.So I invite you to come along with me as we experience something new, and bold, and different this summer – a podcast that serves the entire white collar justice community. I hope you will join me.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZPsychology Today: www.psychologytoday.com/us/therapists…ury-ct/731344LinkedIn: www.linkedin.com/in/revjeffgrant

White Collar Week with Jeff Grant: A Podcast Serving the White Collar Justice CommunityIt’s the Isolation that Destroys Us. The Solution is in Community._______________________Podcast Ep. 03: Compassionate Lawyering,with Guests: Chris Poulos, Corey Brinson, Bob Herbst & George HritzToday on the podcast we have a very special show about compassionate lawyering. We have on three lawyers and one former lawyer whom I know well and respect: Corey Brinson, Chris Poulos, Bob Herbst and my old friend George Hritz.We define compassionate lawyering as giving something more than just a case solution to clients. That is, our four guests discuss putting in that extra mile to help clients find a better, more productive life during and after their issues. They share lots of stories about successes and difficulties in representing individual clients and in advocating for humanistic changes to the criminal justice system.It's an important show if you are a lawyer, if you know a lawyer, and, most importantly, if you hire a lawyer.I hope you will join us. - Jeff____________________Welcome to White Collar Week with Jeff Grant, a podcast serving the white collar justice community. It’s the isolation that destroys us. The solution is in community.If you are interested in this podcast, then you are probably already a member of the white collar justice community – even if you don’t quite know it yet. Our community is certainly made up of people being prosecuted, or who have already been prosecuted, for white collar crimes. But it is also made up of the spouses, children and families of those prosecuted for white collar crimes – these are the first victims of white collar crime. And the community also consists of the other victims, both direct and indirect, and those in the wider white collar ecosystem like friends, colleagues, prosecutors, defense attorneys, judges, law enforcement, academics, researchers. Investigators, mitigation experts, corrections officers, reentry professionals, mental health care professionals, drug and alcohol counselors, – and ministers, chaplains and advocates for criminal and social justice reform. The list goes on and on…In this very eventful summer 2020, our mission is to introduce you to other members of the white collar justice community, to hear their very personal stories, and hopefully gain a broader perspective of what this is really all about. Maybe this will inspire some deeper thoughts and introspection? Maybe it will inspire some empathy and compassion for people you might otherwise resent or dismiss? And maybe it will help lift us all out of our own isolation and into community, so we can learn to live again in the sunshine of the spirit.Along the way, I’ll share with you some of the things I’ve learned in my own journey from successful lawyer, to prescription opioid addict, white collar crime, suicide attempt, disbarment, destruction of my marriage, and the almost 14 months I served in a Federal prison. And also my recovery, love story I share with my wife Lynn Springer, after prison earning a Master of Divinity from Union Theological Seminary in NYC, pastoring in an inner city church in Bridgeport CT, and then co-founding with Lynn in Greenwich CT, Progressive Prison Ministries, the world’s first ministry serving the white collar justice community. It’s been quite a ride, but I firmly believe that the best is yet to come.So I invite you to come along with me as we experience something new, and bold, and different this summer – a podcast that serves the entire white collar justice community. I hope you will join me.Blessings, לשלוםJeffRev. Jeff Grant, J.D., M.Div. (he, him, his)Co-founder, Progressive Prison Ministries, Inc., Greenwich CT & NationwideHost, White Collar WeekMailing: P.O. Box 1, Woodbury, CT 06798Website: prisonist.orgEmail: jgrant@prisonist.orgOffice: 203-405-6249Donations (501c3): bit.ly/donate35T9kMZ

Jeff:Welcome to the VIP Home podcast where we talk about all things homeowners need to know. Today we're speaking with Pete and Megan from Powerhouse, which is a TV show produced with Alliant Energy. Welcome to you both.Caroline:Tell us a little bit about Powerhouse and how it started back in 1996. How did you guys get started?Pete:Well, thank you, Caroline and Jeff. It's great for Megan and myself to be with you guys today to talk about this. We're going to be coming up on 25 years for Powerhouse and Alliant Energy started this back in 1996, because it wanted really to educate its utility customers about the importance of energy conservation and safety, but also to help us save energy dollars. They started the Powerhouse program looking at energy efficiency. It's a 30 minute program that airs in six markets across the Alliant Energy service territory in the upper Midwest on Saturdays and Sundays. Megan and I are very fortunate to be hosting it for the past 24 years.Megan:I have a theater background. Pete is in broadcasting, so we kind of have different background experiences. The cool thing is, is that Pete and I have known each other almost all our lives. We grew up across the street from each other.Caroline:Wow. That is so awesome. No wonder why you guys work so well together.Pete:The number one question we get asked, because again, we know each other so well and play off of each other. They do think we're married. We're married, but not to each other. We're learning and that's the great thing about Powerhouse is that we're sharing the insight that we see in terms of helping customers be comfortable in their homes, be knowledgeable and save dollars and save energy and be more efficient when it comes to energy in the home.Megan:The interesting angle that Alliant has chosen to take it is that Pete and I are kind of speaking for the consumer. We're speaking for the customer. We ask the questions that our audience would want to hear. We don't present as though we know everything. We've learned a lot over the years through this process.Caroline:At VIP HomeLink, our goal is to make the homeowner's lives easier. Although we're homeowners, we don't know everything. That's why [inaudible 00:02:05] wonderful guests like yourselves is so wonderful for us and our bran and to just share knowledge of home ownership with everyone. We like to look into homeowner horror stories, sort of those stories that no one really wants to talk about, but maybe a few years down the road, you get a good laugh out of it or you're frightened to even think of that it might happen again. Do you guys have a story like that, that you could share with us?Pete:One of our first years here at the house that I live in, one of our segments was blowing in insulation up in the attic. Oftentimes, Megan and I, we have the do it yourself projects, and I was helping with our expert to blow in insulation up in my attic. I'm maybe not the most agile or gifted in terms of home projects and I stepped off one of the joists in the attic and put my foot through the ceiling in my house as I was blowing in insulation. I did get the insulation and my attic is much better insulated, but I had to repair the ceiling in one of the bedrooms because I was a goof and slipped off the joists and put my foot through the ceiling.Jeff:You pulled the Chevy Chase from Christmas vacation where he's up there [crosstalk 00:03:10] himself and he just....Pete:Absolutely. Yeah. I did that. That's a bit of my own horror story that I did on one of our shoots.Megan:The crew and I have gotten a lot of mileage out of that through the years. There's a, sometimes they put together a blooper reel and that's kind of fun. Maybe this is just a horror story to me, but they were trying to kind of figure out what the show was going to be and looking back, Pete and I did some things that I can't believe we did. Pete was in the shower for one episode. I was in a hot tub in a bathing suit for one episode.Jeff:Got to get those ratings. I mean, it's [crosstalk 00:03:50].Megan:Oh my gosh. To me, that's a horror story. Then there was another shoot that I remember where they shipped us off to Wisconsin for a catalog shoot. We had all these products that were for sale in helping you be more energy efficient. One section was all about grilling. Well, they do these things so far in advance. I think it was February in Wisconsin and Pete and I are wearing shorts and T-shirts and trying not to breathe so you couldn't see our breath. We were freezing. That was a horror story too.Caroline:I used to intern at a magazine. We did the reverse as well so we were doing Christmas in July and everyone was in [inaudible 00:04:30]. I remember all the models being like, "This is horrible." That is a horror story in my opinion because I [inaudible 00:04:37] serve chilli. No. No. Too much.Jeff:I actually do have a horror story. We bought a condo in Hoboken, fourth floor walkup. I decided, hey, I'm just going to replace the switch. How hard can that be? I watched YouTube videos. I thought I can do this. How hard can electrical work be really watch the video. I did it. I brought my wife in for the big reveal and I turned it on and then you just see like go up the wall and just like burn all the way up. I was like, "Oh my God." Yeah. From that point on, I was not allowed to do any DIY, especially electrical work. We had to do another chandelier in the dining room. I got my very smart, downstairs neighbor who had an engineering degree. He came in and he wired it all. I was just like, "Oh God." Horror stories abound when it comes to electrical work, I can only imagine.Caroline:I feel like that was such a good segue to start talking about how somebody could start their home energy efficiency journey.Pete:We talk about insulation and over the many years of Powerhouse, doing a home energy assessment, we've had professionals that come in and do it. You can also go around your own house and do an assessment. The whole thing about is, is keeping in the wintertime, keeping the warm air in your house and in the summertime, keeping the cool air in your house. Again, not allowing vice versa. Insulation is certainly a great place to start. Attic insulation is a great way to check and make sure you do have enough insulation above you because the warm air rises. If you don't have enough insulation in your attic, that's the first place. We always say, when you do that assessment, start there. Then your walls, making sure that you have enough insulation in the walls, which may be a little bit more difficult.Pete:Again, on Powerhouse, we have a the do it yourself projects, but we also, we'll bring in the experts and the true professionals. We are not the experts. We're sharing the insight and the knowledge. That's the fun part for us. I've learned so much about taking care of our home, being comfortable, energy efficiency. It's the insulation in the walls, making sure that you have enough there even around gaskets, your plugins, making sure that those, it really starts with the insulation in your attic, your walls and in the floors.Jeff:Installation, that sounds like a professional job. What about DIY? Are there simpler things that I can do that are just easy? I run to the hardware store and do myself.Pete:Yeah. You can spend maybe 50 to 75 to a hundred dollars caulking, weatherstripping, going around and checking windows because windows obviously are the biggest source where if you've got gaps in the framing, get a caulking tube and a caulking gun and seal around the windows, weather stripping on the floors. During the wintertime, keep the warm air in from getting outside. Those are very easy things that you can do yourself. We talk about that on Powerhouse. It seems like that's one of those shows every year that we get into, as we get into the winter season.Megan:Led light bulbs. That's newer technology, and those can make such a difference. We always encourage homeowners. It's a little bit more of an investment, but it really pays itself off. What you want to do is you want to take those few lights that you use most frequently, or that are hard to reach, those pain in the neck lights and replace those because they do last much, much longer.Jeff:The technology has gotten a lot better over the past decade I'd say. The one thing about led lights in the beginning was just the look of them. They had this like hospital quality to them, very I'm in an office and it starts flicking of that florescent. Nowadays, I mean, I replaced a lot of our lights, not all of them, but a lot of them with the Phillips hue so it's all smart connected. You can adjust the very, my wife has a very specific setting that she likes the kitchen on and it's called Mrs. White or whatever. It's very customizable and the quality of the light I feel has just completely changed over the years.Pete:The LEDs, the upfront costs are much more than the old incandescent bulbs, but LEDs and the thing that we, Megan and I, have stress on Powerhouse is again, how much longer they last in terms of years for a bulb. We often talk about putting LED bulbs, just start replacing the ones that you have to replace more often that are easy access. As you said, the design has gotten much more friendlier. The lighting's much better. LED bulbs, 95% of the energy goes into the lighting with LED bulbs, which is certainly much different than the old incandescent. Only 5% of a LED is going to energy usage. That's the big thing. It's longer lasting and much, much more energy efficient with LED bulbs.Jeff:We moved into the house and we had all ... all the ceilings were kind of the cheaper ... I don't know if they were LEDs, but they were a certain type of white that, like I said, it was like a hospital flicking on all the lights. I don't know if I'm light sensitive, but it was just like, they had to go. We put them all in a box and gave it back to the builder who redid the house and then made the investment in the smart LED bulbs. Because not only is it customizable, but you can put them on timers, you can reduce your energy consumption that way and make sure at the end of the day, they turn off all the lights and all the lights are off. You don't leave the one in the basement on by accident. I thought that was a really a plus, but downside, they are expensive.Caroline:Do lights on dimmers count, like if you dim your light, does that count as energy efficient? I mean, my fiance definitely has some bulbs that are the LED, but not all, but we have every one on a dimmer.Megan:My guess would be that it would be using less energy.Pete:I would think. The one thing that you do have to make sure that when you buy LEDs, that they do allow for dimming. I mean, you go to your hardware store, you do have to make sure that they are built for dimmers.Caroline:Can we touch a little bit on appliances and energy efficient appliances and how that affects your overall efficiency?Megan:When it comes to your appliances, there are a handful that you really need to maintain well and use appropriately because they use the bulk of your energy. That would be your refrigerator, your dishwasher, and your washer and dryer. Of course, maintenance is important on all three of those things. With your refrigerator, you want to keep the temperature at 40 degrees and the freezer at zero, that's going to be an energy efficient path and still get the job done. Also, I'm going to sound like your mother for a second, but you don't want to leave the doors open. Know what you want out of the refrigerator before you go in there. It takes a lot more energy then to re cool the unit if you stand there with the doors open. Don't forget about the vent and the coils down below the refrigerator. Every year, check that out and clean that out with your vacuum cleaner.Megan:Or if you have a pet, you'll want to do it more than once a year. Check that because that keeps the flow running efficiently. You also don't want to overcrowd your refrigerator. They're designed to basically be full, not jam packed because then the circulation doesn't work. When it comes to the dishwasher, there are a couple of things you can do. You can use the eco settings that are built right into the dishwashers that we buy today and only run it when it's full. Some people are in the habit of doing it every night, whether there are four cups in there or it's loaded and do wait until it's full because you're going to use not only less energy, but you're going to use less water. Another tip is to put it on the air-dry setting. That's going to save you energy too and rinse your dishes off.Megan:Even though the new dishwashers can sense how dirty your dishes are, but do yourself a favor and rinse them off because you're going to get a cleaner wash and it's going to require less energy to do that. To the point that I made about the dishwasher, you also want to take into account when it comes to your washer and dryer. Do full loads. Doing a couple shirts at a time is not going to save you any energy at all. Wait until you have an appropriate load and also use cold water. It'll get your clothes just as clean. Make sure that you clean out not only your lint catch, but also your dryer vent too. That can cause big problems. If you have anyone who is ill in your house, of course, you want to make sure that you put it on this sterilize setting.Pete:In normal times, we talk about washing with cold water, but if you do know that you've got some sick people in your home, in that instance, we do recommend washing with hot water during that time. Megan mentioned cleaning that lint filter in your dryer, but also the duct coming out of it. One of our viewers reached out to us after one of the shows we did and said that he got out his vac and cleaned up the vent coming out of his dryer. It was like a new dryer he said, because it actually dried the clothes much more efficiently. One of the common things that we talk about with your furnaces is changing that filter vent once a month. Most people don't. It's about making sure your furnace is running efficiently and if you've got a dirty filter, it's not going to run efficiently and you're going to use more energy and you're going to use more dollars to run that furnace.Pete:That's one of those things that I always stress. Keep track on your phone, hey it's time the first of the month to change my furnace filter. The other thing that we also recommend is having a service plan. Have your heating and cooling system checked once a year. That's a well worth it 50 to a hundred dollars service call, but to make sure that your furnace, that your air conditioner is running efficiently, again, we'll save over the years, save energy dollars for you and your home.Jeff:It's interesting you say that. VIP HomeLink is an app, and it's basically for people who they have a home, they want to stay on top of these things, but we all know it's easier said than done. You say, "Oh, I'm going to do this." Then life gets in the way. The app is there to actually send you reminders. You put the information in on exactly what your HVAC system is. You can log in your what filter you need, and it'll send you notifications every time you need to change the filter, every time you need it serviced. It'll actually keep you on point there, because like I said, it's one thing to say, "I'm going to do this." It's another thing to actually do it.Megan:A lot of times we tell our viewers, mark a day or think of a day on your calendar and do that monthly. Now, your app sounds luxurious, and I'll certainly look into that, but in a simple way, if you just think the first of the month, I'm going to check my filter.Pete:Probably the one thing that we've done over the years on Powerhouse is if people haven't, it's a programmable thermostat. I know on some of your other podcasts, you've had a smart home, the programmable thermostat. Maybe it's a Nest that you can control off your phone, which is so nice that you can set back at night, turn down that thermostat and save, turn it down 10 degrees. Over a year time and 10 hours, I think you can save something like 10% on your heating bill. There's really savings and again, that's what, here on Powerhouse, we're about. Saving energy, but also helping our customers and our consumers save energy dollars. Megan and I have put in more programmable thermostats over the years. That's another small investment. They can be as simple as maybe a 25 to a $50 investment. Again, you can go up and get Nest and have everything programmed off your iPhone, which is wonderful. That's significant savings in energy and energy dollars.Caroline:I know Ruth is a very smart home tech kind of guy.Jeff:I like the gadgets. When we moved in, that was the first thing I did was let's get the Nest thermostats. Let's get all the security stuff. Let's get all hooked up and you put eco mode on. It kind of just keeps it at a comfortable ... It's not blowing air on you, but Nest will remind me even when to change my HVAC filter, which I didn't know when I bought it. I mean, it's an amazing device.Pete:It really is. Again, I think that's one of the other things here on Powerhouse that Megan and I are very fortunate is to learn about the new technology all around our house. We've done shows on things in terms of reminders with a smart home, to change the filter, to setback your water heater. Some people might be away for a while and they can set back that. It is amazing the technology, the changes that we've seen over the past 24 years of Powerhouse. It all comes back again to helping that homeowner be more comfortable saving energy and saving energy dollars.Megan:Right now it's, we're approaching summer and here in the Midwest, it's really, really hot. That's another thing. If you can program that with your phone, program your air conditioning. You don't have to have it run all day with a programmable thermostat. You can set that to kick in before you get home from work, before you get back from vacation. One of the things that you can do to maintain your air conditioner is to clean it off. We had an episode where I got to do that, and I had no idea that I could do that myself. Of course, I had a professional walk me through it. You just go outside and you have your air conditioner, make sure that it's turned off at the electrical panel.Megan:Then you take your garden hose and you spray it all the debris off the outside and inside the compressor, spray the fins on the inside carefully, starting at the top down so you don't force any debris in there. That's something that you can do that's really, really simple. Another thing is to make sure that you've got airflow around your air conditioning compressor. A lot of people have landscaping and things like that because they want to hide it. Well make sure you keep it trimmed away so you have about a foot, at least a foot around there for circulation.Jeff:I thought I read that it's not a good idea to put a cover on an air conditioner because it can create mold problems or mildew or something like that. Dumb air conditioners, you can go and you can cover it with like an air conditioner cover, which they sell. I assume there's a need and a reason for that, but then I also read you don't want to cover it.Pete:You just got to make sure again, debris and everything's clear. To me that would be the benefit of having it covered, but then you also have to check to see if there's anything that may have crawled up or may have gotten on the fans. Just be aware of that.Jeff:Some resident chipmunks in there.Pete:Sure.Jeff:I did have a dryer vent [inaudible 00:18:54]. I think somebody moved the dryer and it popped out of the wall, but it's so big that we couldn't see behind it. You don't want to scratch the floors and all that. We only knew something was wrong because we'd run the dryer and then it would get really humid and the hallway started fogging up and it turned out that somebody must've moved it and it popped out off the wall. All the wet steam was basically not going where it should. It's just going into the room and we have a small room. That was an issue. We called the professional.Jeff:They came over and charged me four or five hundred bucks to really ... I mean, I was like, "Oh my God, is that really necessary? Can I not do this myself?" He had a whole thing, it goes all the way up to the roof, I guess. He had to put this thing together and clean the whole thing because I guess dryer vents are a big source of fires. There's something like 15,000 fires a year, the NFPA says are caused by dryer vents. It's a real problem. You got to stay up on top of it or else you can put your family at risk.Pete:I think that's a good point. Megan was mentioning cleaning the coils on your refrigerator. I mean, you don't need to do that, but once a year, but again, making sure that that vent is connected properly. That it is again, blowing that hot air and getting it out of your home. Making sure that the vent is clear there and then go on outside where that vent actually vents to the outside, making sure that's clean out there. I just last weekend went and checked mine. I wanted to make sure that I didn't have any issue, but you're right. A dryer vent fires, I hate to say, can be more common than you think, but a little bit of maintenance can help save from a fire. Also, just the overall, again, the efficiency of your dryer operating.Megan:Speaking of vents, I'm going to reverse the season, but if you have a gas fireplace, they vent outside. I know it's important to make sure that they are covered and that when you're not using it, the six months that you're not utilizing it, things can get in there. Animals can get in there. Debris, all of that kind of stuff so in reverse, that's something that you want to make sure that you check out and have a professional look at. Always. We always recommend a seasonal tune up on those appliances, on your air conditioner, as well as your fireplaces and your furnace. That's another vent issue, right?Jeff:I have a gas fireplace. That is definitely now on the top of my list because you know what? I was outside and I was trying to find the dryer vent exhaust, and the guy said it was on the roof. Then there's another vent. I was like, "What is this?" It's the gas fireplace vent. Now I know.Caroline:My parents had a horror story. They were using, I guess their fireplace once. I don't know. [inaudible 00:21:45] not really sure. Then one day there was this squirrel in the bedroom because I guess the fireplace vent wasn't closed all the way. It was just start of fall into winter. There was just a squirrel in the house. If that doesn't count as a horror story, I don't know what does.Jeff:A squirrel in the house counts as a horror story. I've had that in that apartment that I told you about in Hoboken. I had a squirrel. I was home and I walked into one room and my dogs are there and they just start going bananas. I go in the other room and the squirrel had come in the bathroom and walked into the bedroom and the dogs discovered that. It was just going around in a circle, just like on the ceiling. I literally just closed the door and then freaked out. Then I was like, "Okay, I got to do this. I'm not going to trap an animal right now at this point in time." I just opened the window and left. Then I came back like four hours later, just hoping it was gone. Thank God, it was gone, but not after peeing all over my head.Megan:I think I'd rather have a squirrel than bats.Pete:On Powerhouse, again, we've had episodes again, where chimney sweeps, the importance of making sure your chimney is clean and again, having a professional come out and clean your chimney. We've had episodes where they talked about the chimney sweep, talked about different animals that have been found and maybe have been dead there. That also takes me over to cleaning your ducts, your duct work in your house, occasionally is a good thing to do. If you have a lot of pets, it is worthwhile, but again, make sure your duct work is cleaned. It's about efficiency and making sure again, your appliances are operating efficiently. Just like we know with your car, you have an oil change and a checkup with your car. You need to have a checkup of your house system to making sure that it's operating properly and efficiently. Cleaning your ducts, D-U-C-T-S, and making sure that again, that it's functioning efficiently.Caroline:These are amazing tips. We were talking about outside home efficiency so can we just touch a little bit more kind of beyond the AC unit or whatever the real term is for that, and just kind of touch base on some other outdoor efficiencies that would help along your journey?Megan:Well, I think with landscaping, this goes back to the air conditioner, energy.gov says that you can save up to 50% of your energy if you shelter your air conditioner. Shade it with a bush, a tree, of course, distanced. If you think about it, we run more efficiently when we've got a little bit of shade when the heat is pouring down on us. Your air conditioner is no different. Call a professional, make sure that everything is operating smoothly and I will just reiterate what Pete said. The system of your house is designed to be efficient and all your appliances are designed to work well, but we have to do our part and take care of them as well.Pete:Plant that tree to shade your house, your overall house can make a difference. Just a little bit of shade on your house can cool the house so that the sun isn't beating down on it. That's another opportunity. Again, we've done that numerous times on Powerhouse. Come out and plant a tree and again, obviously again, think safety when you're going to plant a tree. Call to make sure you're not digging into a power line. Look up and make sure you're now also not going up into power lines above that might be up there. We always stress safety on any, do it yourself projects on Powerhouse.Caroline:People like Jeff Ruth here might take things into their own hands when they should be calling a pro.Jeff:Felled enough trees in my day that I know to call a pro.Megan:One thing that can make a real difference in your energy usage is how you plug in all of the things around your house. You think about all of the cell phone chargers that we have on the small end, but then we also have our home office. We have all kinds of little appliances, toasters, things like that, that we don't use all the time, but they are always drawing power. We call that phantom power. That phantom energy can really add up, up to 10% of your utility bill. That's huge. I have a prop for you. This is a smart strip. What this has is different plugs here that will remain on if necessary, like say your wifi router. You don't want that to go off. There's a designated place for those items, but for the things, video game systems, things like that, that you don't use all of the time, your DVD player, things like that you can put in here. Then it actually will sense when you're not using it and shut those things off.Caroline:That is an amazing product.Jeff:Yeah. We're going to definitely recommend because I need one. I'm going to find one, we're going to recommend it to the listeners and give some links out there so you can find the right one for you.Pete:With your ceiling fans during the summer, they are pushing the cool air down. You want to make sure it's spinning the right way to push down. In the winter months you want to pull the warmer air up. Remember when you're out of a room, I remind my family to turn off ceiling fans if you're not in the room.Jeff:Is that because money doesn't grow on trees?Caroline:You mentioned the right way. There's clearly a wrong way. Is the right way for cool air counterclockwise or clockwise or [crosstalk 00:27:25]?Pete:Well, again, making sure you can feel it when you turn it on. Is it pushing down? I mean, you can feel it pushing down. Make sure it's spinning that way. I'll let the listeners check themselves, okay?Caroline:Perfect. Perfect. Your website, discusses home energy assessments. What would that entail and how does a homeowner know that they're ready for such an assessment?Megan:On the Alliant Energy website, we offer an energy assessment and you enter all of your specific information in there, and it's really basically a checkup for your home. It offers recommendations of ways that you can improve and it's something that once you make those improvements, you can then watch your utility bill and see how things change after you do that. I would say every five years, you can revisit it too. If you've done any other home improvements, you can plug those in. It just kind of keeps things up to date. It's not unlike your app actually. You can keep all of that in one place as well.Jeff:We have a lot of things in common. I'm definitely excited to check out more about the Alliant Energy assessment. Can you tell us a little more about where to find that and how to, is it for just people in the service area or can anybody go and get tips there?Pete:Most utilities, again, I think around the country are offering that. I would always say to your listeners to check with your utilities for what kind of services they provide in terms of a home energy assessment. I think most energy companies today are trying to be good citizens of our Earth and are looking at ways to make sure your home is energy efficient and offering that. I would say check that. One of the things that we stress on Powerhouse is energy star rated appliances. When you're going out to look for new appliances, make sure they have that energy star on the product.Pete:Maybe you've got that second old sort of a beverage refrigerator or beer refrigerator that maybe is 20 years old, but it sure keeps those beverages cold. That's not always the best use of that old refrigerator because they really burn through energy. A fridge that's about 15, 18 years old, it might be time to look at a new refrigerator because they are so much more energy efficient here today than just 15, 20 years ago. You can save again, a lot of energy dollars that you're paying to keep those beverages cold.Megan:Another service that Alliant energy offers is a refrigerator recycling program. To Pete's point, you want to check with your utility company and see what services they offer, because you might be surprised.Caroline:Thank you for all these tips. I mean, I'm so enlightened. Knowledge is power they say.Megan:People are sheltering in place and their home a lot more. Their utility bills are creeping up because of that. With the use of the home office, kids playing video games, all kinds of things, homeschooling, using your computer more than you might have before. People are cooking a lot more. There are ways that you can use your kitchen a little bit more efficiently, and that is to scale down your appliances, especially as we're approaching summer. Grill outside. It's a common sense thing. Use your crock pot, a slow cooker, toaster oven, they use so much less energy than torquing up your oven.Megan:Also, you can scale down how you use your stove top as well. You want to make sure that you use your cookware appropriately by using the right pan size so you're not wasting energy by extra heat coming up. Also, put lids on things. That's going to speed up your cooking and it's going to use less energy too.Caroline:I know my fiance doesn't quite get the toaster oven versus the oven. I'm really trying to help him out there. It also got so warm that the toaster oven is, it seems a bit quicker, but it also doesn't make the whole place like it is outside.Jeff:I think one of the best wedding gifts that I ever got was the Breville toaster oven. It's like-Caroline:I just said that, for our wedding.Jeff:It's great. I mean, I use it every day.Megan:It's fast, quick, easy. You can watch it happen and it doesn't heat up the kitchen.Pete:Brilliant. Again, appreciate being able to, Caroline and Jeff, to talk with you guys and share tips with your listeners. As we like to say, always as we finish an episode of Powerhouse, with these tips and ideas and saving energy, we can make your house a power house.Megan:A powerhouse. Visit our website, Powerhousetv.com. There are loads of tips on there.Caroline:Thank you so much, Megan and Pete. It was so lovely to have you both. We hope that we can partner again soon. Our missions really align in that we really have a lot in common. We'd love to have you guys back on the show one day.Pete:Thank you.Megan:We would love it. Thank you.Jeff:Thanks guys. Have a good one.Caroline:Have a great day.Megan:Thanks. You too.Jeff:Bye.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60. Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness. Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures. Nachi: So there must be guidelines for those recent post-op for flying - right? Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room. Nachi: Then why are people always getting sick after flying…? Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back. Nachi: Interesting. Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day. Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away. Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology. Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions. Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at. Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies. Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies. Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions. Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology. Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases. Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control. Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board. Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies. Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome. Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available. Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening? Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight. Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus. Jeff: For many ED providers, functioning as a consultant will be unfamiliar. Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school... Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act. Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation. Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.” Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard. Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution. Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services. Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in? Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly. Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert? Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable. Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here... Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate. Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference. Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble. Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort. Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight. Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it. Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections. Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls. Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights. Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets. Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol. Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events. Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases. Nachi: AEDs are required on all US-based flights. Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity. Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act. Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct. Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence. Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances. Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%. Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection. Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important. Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine. Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: The [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

The guys talk about the television they’ve been watching so far this summer, including American Ninja Warrior on NBC, FX’s Pose, American Masters: Terrence McNally: Every Act of Life on PBS, Grand Hotel on ABC, Good Trouble on Freeform and What/If on Netflix. Jeff reviews In Case You Forgot by Frederick Smith & Chaz Lamar. Jeff interviews Roan Parrish about Raze, the latest book in the Riven series. They talk about the research she did for the series, including going on tour with a band, as well as the eclectic music she enjoys. The origin of Roan’s collaboration with Avon Gale is also discussed along with what got Roan started with writing gay romance. Complete shownotes for episode 196 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript - Roan Parrish This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Welcome, Roan, to the podcast. It is so great to finally have you here. Roan: Thank you. I'm so happy to be here. Jeff: And it's a perfect opportunity because just last week, you released raise "Raze," just the third book in the "Riven" series. And for those who don't know, tell us about the series and, of course, this latest installment. Roan: Sure. So "Riven" starts out with the book, "Riven," also the series title. And it's kind of an anti-rock star romance. It's about Theo, who's the lead singer of the band, Riven. And they've suddenly hit it big and are super famous. And everyone in the band loves being famous and their success. And Theo hates it. He hates being famous. He hates being the center of attention. He hates, like, people knowing things about him or looking at him when he leaves the house. So he loves the music, but he finds fame, like, the worst thing ever. And so he's about to go off on a new leg of the tour and is sort of, like, wandering the streets of New York, feeling a little bit sorry for himself. When he hears this song coming from a bar, like, someone just strumming guitar, and it's one of the most beautiful things he's ever heard. So he goes in the bar to see who's playing this or what the song is. And he meets Caleb, who is the one playing the music. And Caleb, we learn later, has been a musician for a long time, a working musician, but has sort of gone away from the scene and hidden himself away in his uncle's house out of town because he's had some addiction issues, and he's trying to stay clean by staying away from everything that reminded him of the scene, including music. So they start to talk to each other and they bond over music. And then little by little, they fall in love. The problem being, of course, that for Theo being in the scene and being public is kind of part of his thing. And for Caleb, everything about that just brings back a lot of bad memories. So they have to sort of work together to figure out how that's gonna impact their relationship and if they can get through it. And then it kind of takes a hard left, I feel like this is the thing that I should say for people who haven't read the series, is that the series really does hang together. It has the same secondary characters. It deals with a lot of the same themes, like, the themes of ending up someplace that you never thought you would be. But then in book two, we met Reese, or we've met Reese in book one, but we have a book about Reese who was Caleb's best friend and Reese's husband, Matt. And Matt has nothing to do with the music scene. And the book is told from his perspective. So for people who go in expecting that the whole series is about music, it is in some ways, like, music as a through line. And certainly, this idea of fame and this idea of struggling with fame is a through line. But book one is sort of anti-rock star. And then book two is like working musician and person who's not involved with music at all. So I feel like that's the thing I should say. Jeff: Well, they it does hang together because you've got the working musician. Roan: Yeah, totally. And Reese, who is the working musician is someone who toured with Caleb when Caleb was still playing music. So the characters all hang together and the series hangs together, but it's not a kind of musician book, if that make sense. Jeff: Yeah, that makes sense. Roan: And then "Raze," which is book three, it also hangs together. "Raze," it's similarly about characters ending up someplace that they never thought they would be. And in this book we meet Huey, who was in the first two books, and has been a sort of a little bit of a shadowy figure who we never knew his backstory, we didn't know who he is, he just pops in and dispenses wisdom, and pops out again, he doesn't say much else. And so he was Caleb's sponsor in Narcotics Anonymous. And he's still been working as a sponsor. And he is so used to taking care of everyone else being a sponsor, helping people work through their own addiction issues, dealing with his own, that he doesn't really ever focus on his own life. He's built up this kind of wall of focusing on everyone else, so he never has to think about himself. And we meet Felix, who is doing the same thing, taking care of everyone else but him himself, but through his family instead of through NA. So he grew up and help take care of his younger brothers and sisters, and always helped his sister get whatever she wanted, and has now found himself as his sister goes off to do her music thing, found himself kind of like, "What the hell am I doing with my life? Who am I? I kind of forgot to ever notice what I wanted." And so the two of them come together. And two people who are so used to looking out for everyone except themselves, as you can imagine, when it comes down to trying to make a relationship, they kind of don't know how to do it. They don't know how to ask for what they want. They don't even know what they want from each other. And so feelings kinda bubble up and nobody knows what to do with them. And then it ends really happily. Jeff: As all romance must. Roan: That's a must. And there's even a kitten. So, yeah. Jeff: What attracted you to writing this series? Roan: I think that there's themes that go together. I love music. And I've always been a huge music fan. And one of the things that I've always thought was interesting is that music is so personal, to me, anyway. And I know for many other people, like, each of us, listens to music and feels something - has associations that are deeply personal. And something about the weirdness of something so personal, experienced on a large scale of fame has always struck me as really odd. So you can be at a concert with the band and have thousands and thousands of people there. And each person has been hit with his music in a really personal way. And yet, we're all there together in a super public space, having kind of a personal experience, like, smooshed up together with each other. And I've just always found that really strange. And I know for people who make music, the process of making music is really personal. And it's really different than the process of performing music. And so I think I was interested in what would it feel like to do something really personal in front of a lot of people and then watch as this thing that you've made gets loose on the world, and you no longer have any control over it or what people think of it. And to me being famous seems like absolutely the worst thing I can imagine outside of, like, actual torture. And I know that for some people, that's not the case. But, yeah. So I was interested in writing, like, the genre of rock star romance is a thing. And I was interested in looking at it from the perspective of what would a rock star romance look like, if instead of rock star being a desirable thing, it was a terrible thing or a thing that caused a lot of problems for the rock star. Jeff: What was the process around some of the research, because, like, you talk about this very personal thing. How do you research that? And then how do you try to read and put it in a book so everybody else gets it? Roan: You know, I mean, I don't know. I can't really claim that I did it correctly. I've never been a musician. I like singing karaoke to Paula Abdul once with five other people very drunk in college. And that's about my performance level. But my sister-in-law, my sister's wife is a musician. And she's very personal and writes very personal music and then performs it. And, you know, I've been to many of her shows, obviously. And I went on tour with her in Europe once, like, carrying her stuff and hanging on for the ride. And one thing that struck me was, like, people would come up to her after the show and tell her like, "Your music has meant so much to me. I was going through such a hard time and your music spoke to me in these really hard moments." And so I would see that and I know that people are having these personal responses and have personal relationships with the music. And I know that my sister-in-law does as well. And then, like, the moment that the two of them would be having together would be personal. But there was still this whole performance element that I kinda…yeah, just seems like a very strange crucible of the personal and the public smooshed together, and maybe the performativity of that, in some way, like, hides the personalness…or not hides necessarily, but, like, you need a little bit of distance, like, the lights and the smoke machine, and the darkness, and the space between the stage and the crowd to insulate you a little bit in order to take something that's so personal and project it out in public. Jeff: I love how you kinda had the personal research going on there that you actually went on this tour and got to see all of it kinda go down about as close to it as you could without being the actual performer. Roan: Yeah, yeah, which is awesome. And I mean, like, I've had many friends who do music. So I knew that if I had, like, specific questions, you know, I had some questions about, like, the studio stuff and how you laid out tracks that I was able to ask friends about. But I really do think it's, like, the feeling of performing that I was trying to capture and the sense of what it felt like to have something that was yours, like, the music, and then watch other people make it theirs. And although I've never been a performer in any way, I mean, that's a little bit, like, what happens with books is that I sit at home in my pajamas, like, with cat hair all over me, and I write these books. And then when they're published, it's not mine anymore, it belongs to the people who read it. And I don't really have any control over it. So that part was easy to kind of understand. Jeff: Of course, you mentioned your love of music. And your bio actually mentioned that you listen to torch songs and melodic death metal. Now, I get eccentricity because my playlists are, like, wildly, you know, strangely hooked together in some way. But these two seem very different. What attracts you to these two individual styles? Roan: I think I was trying to write my bio in a way that was, you know, like on dating sites, you wanna say the two things that seem most opposed. So you can be like, "Listen, this is what you're getting as a human being who is essentially at odds with himself," maybe that's just me. Anyway, yeah, I love both of those genres. I think they're both simultaneously really raw and really beautiful. Like, torch songs, I love because they are heartbroken, and tender, and they tell a story, and they're so vulnerable, and beautiful. And melodic death metal is like, doing the same thing, only it can't be vulnerable, or, like, it needs a really harsh bass riff, and loud guitar, and loud drums in order to do something that's that tender and that personal. And I find not like screamy death metal, but yeah, melodic death metal. I find it like one of those puppies that growls at you until you get a little bit closer, and then little by little it sorta lets you pet it. And then by the time you're petting it, it's like, "Oh, no, I really do love this. Please don't ever stop petting me," but then, like, someone else walks in the room and they're all growly again. Jeff: I love that analogy. So awesome. Jeff: Now, speaking of music, with the "Riven" series seems such an obvious thing to perhaps you write to music if you're a writer who does that. Was there a particular playlist that sort of pushed you along in the writing of the series? Roan: You know, I actually didn't listen to music at all writing the series, which is sort of strange when you say it like that. I go through phases of whether I like to write with music on or not. And there have been books that I've written where I listened to the same music over and over. Like, when I wrote...what book was it? Oh, "Out of Nowhere," which is the second book "In the Middle of Somewhere" series, I listened like obsessively to "The Civil Wars" just over, and over, and over. And for some reason, the mood of those albums was, like, exactly the mood that I needed to be in to write that book. But with the "Riven" series, I didn't listen to music at all. Jeff: Interesting. Okay. Roan: Yeah. And none of the music in the books is real. Like, I made up all the band names and all of the music. And I wonder if maybe part of it was like, I didn't want real music in my head because I was making it up. Jeff: That would make sense. Yeah. If you're having to write any kind of song lyrics or anything inside the book, I could see where you would wanna, like, accidentally just pick up something. Roan: Right. Well, it was super adorable actually because one of my best friends who reads all my stuff first is, like, she likes music a lot, but she's like a top 40 radio kind of tastes music person. And so she thought that all of the musical references in my books in the "Riven" series were real, because she knows that I like lots of different kinds of music, and she just didn't know that they were fake at all, which is totally adorable. Jeff: Oh, that's awesome. So you could have an extra career then as a songwriter if you're writing lyrics. Roan: Maybe a band-namer. I like the band names more. Jeff: So I have to ask for the audio book then that you've got song lyrics - does that mean your narrator is actually singing the lyrics? Did you make Iggy sing and Chris sing? Roan: No. And, you know, I don't think that I have a chunk of lyrics long enough to be sung. They're like a couple snippets. But I didn't even think about the fact that I could have written a song of it for the audio book. That would have been awesome. Too late. Jeff: Something to think about maybe for a future book or another installment in the series. Roan: Yeah, yeah. I could do it as like an extra or something, I guess. Jeff: And speaking of the series, is there more to come in this series? Roan: There's not. Like, The Good Place that we were talking about earlier, I have decided that book three is the end. Jeff: Okay. Time to wrap up that universe. Roan: Yeah. And, you know, I say that and obviously maybe I would go back in the future and write another one. But I think the fact that the last book is about a character whose story we've kinda been wondering about for the whole series, it felt like a good place to stop because it's sort of the wrap up of, like, solving the last interpersonal mystery. So that felt like the right place to stop. And there are definitely tendrils. Like, people who've read a bunch of my books will notice that Riven, the band, is mentioned in another book, and that some characters from the "Middle of Somewhere" series are briefly alluded to in "Riven." So there's, like, little Easter eggs for people who have read all the books because I sort of think of everything as being connected in that way. So it'll pop back up, I'm sure. Jeff: I love that. I love the broad interconnected universe thing. Roan: Yeah, yeah. Secretly in my head, all of the books are connected in lots of ways that I don't necessarily put on the page. But, like, I like to get a couple in there. Jeff: Nice. Now, you also co-write with Avon Gale. What got that collaboration going? Roan: You know, that collaboration happened completely by accident, or on a whim, I should say. And I'm so glad it did. So I was living in New Orleans a couple years ago. And Avon and I were friends on the internet. And she offered when I was moving back from New Orleans to Philadelphia, she was like, "I love a road trip. What if I fly to New Orleans and drive with you," because it's a many day drive and you have a cat. I had like my truck and then I had my car hitched to the back of the truck, and it was a whole big thing. So I was like, "Oh, great. This will be fun." So we started driving from Louisiana to Pennsylvania. And it was, like, a torrential downpour. And we couldn't hear the radio. We couldn't do anything. And so Avon was like, "Okay. Well, I'll just tell you about this book that I've been working on. And I am really stuck on it. I can't get the plot right." So I was like, "Okay." And I'm pretty introverted and Avon is very extroverted. And we going in... Jeff: And it's very true, she is. Roan: Yes. And, you know, I really just love a clear communicator, so I loved it. She was like, "Basically, I talk constantly. And if you want me to stop, you have to tell me to stop." And I was like, "Oh, that's amazing. I run out of steam socially in approximately two-and-a-half hours, and I'm still listening to you, but I won't respond." And she was like, "Okay, great." And thus, it was. And so she basically narrated to me the entire plot of this book that she was trying to write, and she was having trouble with it. And I kept doing this probably obnoxious thing where I was like, "Oh, what if you did this?" Or, "What if you did that?" Or, "Oh, my gosh, it's so funny, because if that were me, I would totally do this." And she, instead of being annoyed, was like, "Well, you should obviously write this book with me." And that book was what it turned into "Heart of the Steal," which is the first book we wrote together. And it was so fun because then as we were driving, we just plotted the whole book. And she had her little, like, computer that she was typing on while we drove. And I drove the truck the whole way. And so I would like yammer at her and she would take notes, and then in the hotel rooms at night, we would kinda hash it out. And so it happened on a total whim, and then turned out to be really fun. And so we planned it on that trip. And then I went and visited her months later, I guess. Yeah, some months later, and we actually wrote "Thrall," which was the second book that we co-wrote together, like, in the same place. So we wrote it, like, together, even though we don't live in the same place. So it was two very different writing experiences, but both equally awesome. Jeff: That's fantastic. And I have to imagine it's a nice way to kill the time in a road trip to just write a book. Roan: Oh, yeah, totally. And it's really fun because I don't know about you or about other writers in general, but, like, I find that traveling is one of the best, like, brain, what do you call it? Like, catalyzers, brain catalyzers, something about moving through space constantly, whether it's, like, on a train or just walking or whatever. It's, like, the rhythm of moving through space makes my brain also work in a forward rhythm. And I find myself, excuse me, getting so many ideas when I'm just, like, walking a long distance, or on a train, or on a bus, or something. And so something about driving and plotting the thing together was, like, super, some word… Jeff: Awesome. Roan: Yeah, awesome. Jeff: Probably better than awesome, but awesome was the first thing that popped into my head. Roan: Yeah, yeah. Jeff: And then I totally get what you're talking about there, too, because I've done a lot of plotting and some writing on planes. Because it's like, yeah, there's something about just that that just you've got the time, and, like, the brain is working, so use it. Roan: Yeah. And it's, like, looking out the window of something moving through that kinda space with everything passing so quickly, it almost feels like it changes the rhythm of thoughts or something. Jeff: Yeah. And kudos to Avon for being able to type in a moving vehicle because I don't know that I could do that. Roan: Oh, my God, she has, like, motion sickness proof. I swear to God. Jeff: That's just crazy. Roan: Oh, I know. Jeff: But we definitely got to talk a little bit about "Thrall." I reviewed it back in Episode 157. I was just blown away by it. For folks who don't know, tell us about what that book is and what in fact does make it so special? Roan: So "Thrall" is our modern "Dracula" retelling, basically. And for anyone who's read "Dracula," you'll remember that "Dracula," it's an epistolary novel, so it's told through letters, and diary entries, and, like, newspaper clippings, telegram, stuff like that. And so we did "Thrall" in the same way, we made it an epistolary novel. But since ours was modern, and that one was 19th century, instead of letters and journal entries, and stuff like that, we have emails, and g-chats, and tweets, and podcast descriptions, and stuff like that. So the whole thing is written in that way, this combination of different print media. So we have the main characters that people will recognize from "Dracula." And Mina, and Lucy, who are the two characters that people will know from "Dracula," in our version, have a podcast, a true crime podcast in New Orleans. And they get caught up in basically trying to solve the mystery of Lucy's brother who seems to have disappeared. And so in getting caught up in that mystery, they stumble upon this a role-playing game kind of thing, where they use an app, and they go to different places, and they try to solve clues, hoping that it will take them to Lucy's brother. And so in addition to it being an epistolary form in general for the whole book, then kind of within that epistolary form, there's this mystery that they're trying to solve on a computer, I mean, on a phone app. So it's like a game inside an epistolary novel that's an adaptation of another epistolary novel. Jeff: And epistolary just not something you see very much. At least I don't, especially in the romance genre that I tend to read in general. What was it like as a writer, and just plotting to take on such a different narrative format? Roan: Yeah, it was awesome. It was really, really cool. I love form, like, I'm super interested in what different things you can do with form. And one of the things that, like, when I'm reading other things I'm always interested in is what form did this author choose, whether it's something simple, like, short chapters, or long chapters, or, like, flashbacks versus telling everything in order, all of that stuff, I think, has such an impact on the way the story gets delivered. And so I was really excited to play with the form. And I think that with the genre of romance, one of the reasons why we don't see epistolary stuff so often is that it's, like, an additional level of remove between the two characters. And romance seems, to me, to be all about intimacy and connection. And sure, it can be really romantic or sexy to write a love letter or love email, I guess, in 2019. But there's still something where you're not in the moment. There's no, like, tracking a touch as it happens, or a kiss, or whatever it is. And so I think that going into "Thrall," we were like, "How the hell do we make a romance happen when the characters essentially are never in the same scene?" Like, in order to be texting each other, they probably aren't together. In order to be chatting each other, they're probably not together. And so any evidence of an encounter, which is all we could show, also demonstrated their distance. So that was a challenge. And we got around it in a couple of different ways, including characters literally writing out sex scenes that they wished would happen like fantasies, having chats that were more intimate. But yeah, the romance part, I think, was actually the hardest to portray via the epistolary form because it introduces that necessary distance, which is sort of the anti-romance. It was much easier, for example, for the mystery, or the suspense parts because those things can be portrayed that way no problem. But, yeah, the romance part was tricky. Jeff: Well, as I said the review, I think you guys pulled it off so amazingly. If people have not read "Thrall," they should really pick it up and give it a try. Roan: Oh, thanks. Jeff: Because maybe a little much to call it a breath of fresh air, but it's certainly gonna be something very different than what I think most people tend to read. Roan: Yeah, it definitely is different. And it's one of those books that Avon and I knew going in, but it's not everyone's cup of tea. It's an adaptation. It's an adaptation of "Dracula." It's an adaptation of "Dracula" without vampires. It's a romance where you don't ever see the characters touch necessarily. But like, I feel, like, for people who are interested in form for people who are interested in Dracula or interested in suspense, and all that stuff, we were really excited to just do something totally new for us. Jeff: Yeah. It was super cool. Please do more of that sometime. Roan: I would love too. Jeff: So laying a little bit of your origin story, how did you get involved in writing M/M romance? Roan: You know, at the risk of making, it sound completely accidental, it was kind of accidental. My good friend from graduate school, got a job in Phoenix, and didn't know very many people. She didn't have many friends. And she and I both started reading both young adult and M/M mysteries in grad school. And so I went to go visit her and she was having a hard time. Like, I said she didn't know very many people, didn't have any friends, and she just wanted like, escape reading. And we were, like, in the kitchen cooking dinner or something, and she was saying that she just wished that there was, like, a romance novel that she could read about someone who was in her situation. So someone who was a new professor in a new place, didn't know very many people and was kind of struggling to fit in. And because she's my friend and I wanted to make it all better, I was like, "Oh, no worries, I'll write you a story. Everything is gonna be okay." So on the plane home from Arizona, I wrote the first chapter of what would eventually be "In the Middle of Somewhere," my first book, thinking that, like, I would send it to my friend, and she would read it and be like, "You are such a nerd. I can't believe you actually wrote me this story. I was just complaining. You're weird." But instead, she read it and wrote back and was like, "Oh, a story. Oh, my gosh. What happens next?" And, of course, I didn't know what happened next because there was no next. I thought that it was going to be a little one-off thing. But then I wrote the next chapter and I emailed it to her, and she wrote back and was like, "What happens next?" And I actually wrote the whole first half of the book that way just chunking out a chapter, emailing it to my friend, and I was really writing it for her. I never thought I would show it to anyone. I never intended to send it to a publisher. I didn't even have a plot, I just was writing these little sections. And around halfway through the book, I suddenly realized that, like, it was getting kinda long, and I should probably figure out how it was gonna end. Otherwise, I would just end up writing this, like, email missive to my friend forever, which was really fun. But also, I thought she would get sick of it eventually. And then when I finished the book, I thought that was gonna be the end of it. And it was my friend who was like, "No, you should totally try to publish it." And I owe it all to her, I never occurred to me to send it to anyone. And I would never have done it if she hadn't made me. Jeff: Well, kudos to her for making that happen. And that's the best accident story ever. I mean, just amazing. Were you writing before that at all? Or was this just really like, "Hey, I could write. I'll write you something. No worries." Roan: Well, you know, I've always written different things. I was a poetry major in college of all the super useful things to pursue. And so I wrote poetry or some short fiction. And then I did my PhD in literature. So, you know, I wrote a dissertation, I wrote nonfiction for years, and years, and years. But I've always loved to write. And I love reading novels. And so sitting down to write a novel, I think it actually helps that I wasn't thinking of it as writing a novel. I just thought of it as writing the story for my friend. So I didn't have any of the self-consciousness or like that internal editorial voice that I'm sure if I had planned to send it out, would have like, killed me as I was trying to start. And in terms of, like, as we get back to your original question, which I don't know that I actually answered in terms of, like, why M/M romance specifically. I hate misogyny, and sexism, and can't deal with stories where I read female characters and feel intensely alienated from them. And I find often in romance, not all by any means, there are some amazing, amazing, like, revolutionary really amazing people writing romance with women, but I've often found that reading romance novels that are, like, heterosexual romance stories make me feel alienated, and angry, and the opposite of anything that I associate with romantic. And so, yeah. Jeff: Who are sort of your author influences? Roan: Oh, man. Well, you know, growing up, I read everything. I'm a real, like, moody reader. So I go through phases. And when I'm in that phase, that's all I read. So, like, when I was in elementary school, I was obsessed with S. E. Hinton Hinton, "The Outsiders" and "Rumble Fish," those books. And she writes with this very kind of, like, spare style, but lots of sensory detail. And I think that that's definitely something that I've always really admired was the ability to evoke feeling even while being very spare. And then when I was in middle school, I was obsessed with Anne Rice, obviously, because middle school. And I read her books over, and over, and over. And I think that she is like the master of the kind of Baroque sentence structure that when you're deep in, reading one of her books, you don't notice that she's, like, in a strange Yoda way, like, flipping a subject and predicate to make things sound, more flourishy and purple prosy. You don't notice it because you're so deep in it that, like, of course, that character would talk that way. But if you go and you read another author or another book, you realize suddenly what she was doing. And so I think from her, I got just, like, I really respected this immersive detail-rich all the senses engaged kind of writing. Also, I really love long books, and the ability to sustain a story over 800 pages, and keep going with this level of detail. I mean, I know it's not everyone's bag, like, some people really like a short one and done, but I mean, I will read a series that goes on forever if I'm still engaged. And I just think that she does that incredibly well. Then, oh, gosh, I'm taking you on a tour. I don't know if this is actually answering your question, but I do think... Jeff: It is actually. Yeah. Roan: Oh, okay, good. The real answer is, like, I learned things from every single author I read. And sometimes, it's things that I don't ever wanna do. And sometimes, it's things that my mind is blown because I'm like, "Holy crap, I didn't even know you could do that." Sometimes it's like I feel like I'm weak in one area at a moment. And so I wanna go read someone who I think does something really well and try to learn it. Oh, Francesca Lia Block was a huge influence when I was a teenager. She writes this kind of magical realism that is, like, very urban set - in LA, deals with real world problems, but has this, like, pink fog over the entire thing. And I was really, really taken by that. That way of combining urbanity with fantasy, and so that's definitely something that I took from her. I went through a really deep, like, epic historical fiction kick, which maybe is that same kind of, like, very immersive detail, huge cast of characters, all that stuff. And, oh, gosh, I'm totally blanking on her. Oh, Sharon Kay Penman is her name. Okay. Sorry, this is maybe a tangent. But this story blows my mind and is, like, one of the more impressive things I've ever heard in my life, if you'll indulge me for a moment. Jeff: Of course. Roan: So Sharon Kay Penman writes these, like, hugely epic, 1,000-page long, British Isles historical fiction. And she wrote this book called "The Sunne in Splendour," in, like, I wanna say the early 80s, maybe mid-80s. And the book is epically long, and just detail, and hundreds and hundreds of characters, and like tons of things translated into Welsh. It's about Welsh civil wars, or wars with England. Anyway, she wrote the book and, like, on a typewriter, and had it in one of those, you know, the boxes that reams of paper come in…you would put your manuscript in this box. So she was going to drive her book to her publisher. And she stopped at the bank to, like, deposit a check or something. And when she came back out, her car had been stolen with the copy of the book inside, the only copy of the book, which I don't even know how that happens. So the car stolen, she's just sure she's never gonna get it back. And whereas, like, I don't know, I would probably immediately go home and, like, order seven pizzas, and you wouldn't see me for a month. She drove home and started writing the book again. Jeff: Wow. I would have done the seven-pizza thing and then walked away for, like, at least a week. Roan: Yeah. Like, I would have told every single person who would listen that my life's work had been ripped from me. And it was the worst thing that ever happened to me and which, you know, I think that's actually speaking pretty well of my life that that would be the worst thing. But, yeah, I just, like, that level of tenacity and dedication to a project, it just blows my mind. Anyway, she's amazing. Jeff: Yeah, that's awesome. And just, like, I can't even imagine, it speaks so well to these days where we're like, "Did you back that up on Dropbox?" Roan: Yeah, at least someone's like, "Oh, man, I just spent, like, 20 minutes writing that email and it got wiped." And I'm like, "Sharon Kay Penman." Jeff: So what's coming up next for you? What's yet to come this year? Roan: Well, do wanna be the first person to know because I actually just found out yesterday? Jeff: Oh, breaking news. Roan: Breaking News. Yeah, I just sold a new book, which I'm pretty excited about. Okay. The concept is, there is a guy who has a bunch of animals. He's like, kind of antisocial, kind of pissed off at the world for reasons that I will not divulge yet. And he likes animals better than people. So he has all these rescue dogs and a bunch of cats that hang around. And basically, all he wants to do is take his dogs on these long rambling walks and think about how fucked up his life has gotten. It's the only thing keeping him sane, it's just, like, rambling walks with these dogs. And one night he is walking with the dogs and one of them starts chasing something. And he starts chasing the dog and falls down a hill and breaks his ankle. So all of a sudden, he can't do the one thing that he's liked, which is walk his dogs. So he goes online, and he finds this app that, like, match makes pet owners with people who wanna hang out with animals, but can't have pets of their own, because he's looking for someone who could help him walk his dogs, since he can't do it anymore. Then you have this other character, who's super shy lives with his grandma is, like, husband saving up to try to, like, get a new apartment so that he could have a dog. And then his grandfather dies, he has to move in with his grandmother, and he can't have an animal because she's desperately allergic. So he goes on the matchmaker app, and gets matched with this dude who needs someone to walk his dogs. And so the Meet Cute is a dog walking app, and a grouchy meets a shy guy, and lots of animals, and love. Jeff: Well, this sounds awesome. When do we get to see this? I'm guessing 2020 sometime? Roan: I think so. I don't have a date on it. I'll start working on it soon. But, yeah, I think it's gonna be, like, cute-ish in tone. And I don't know, I keep, like, accidentally writing animals into every single one of my books. And I don't even mean too. And this time. I was like, "Well, I mean, I keep doing it by accident. Maybe this time, I'll just, like, actually do it on purpose." Jeff: And what's the best way people can keep up with you online and find out when this next thing comes out? Roan: Well, they can check out my website, roanparrish.com, where I post all things that exist. And then in terms of social media, I've been very active on Instagram stories lately. I just bought a house, my first house, like the first non-one-bedroom apartment that I've been living in. And I've been doing all these, like, garden planting, and baking, and projects, and stuff. So I've been really liking Instagram stories. So people should follow me there and tell me all the things that I'm doing wrong in my garden. Jeff: They may not think you're doing wrong. Roan: I mean, it's my first time and I feel, like, I'm doing everything wrong. But we'll see, it might grow. Jeff: I bet it does. And congratulations on the first house. That's such a huge thing. Roan: Oh, thank you. I really went, like, in the space of one month from a person who thought that they would always live in one-bedroom apartments to a person who bought a house. And so it was very shocking for me. I keep wandering to the extra room and being, like, "What's gonna go in here? I don't know." Jeff: It's part of the fun of home-ownership. Roan: Yeah. Mostly, it's like my cat goes in there. And that's what happened. So I mean, I'm on all the social media things. I'm everywhere as Roan Parrish and people can find me. But Instagram stories is totally the most fun. And for people who, like, wanna know about when books are coming out, but don't dig the social media vibe, BookBub is a great place to find me because they'll just get emails when I have books coming out or on sale. Jeff: Fantastic. Well, we will link up to everything we talked about in the show notes. We wish you the best of luck with the release of "Raze." And thanks so much for hanging out with us. Roan: Oh, thanks so much. It was a blast. Book Reviews Here's the text of this week's book reviews: In Case You Forgot by Frederick Smith and Chaz Lamar. Reviewed by Jeff Frederick Smith and Chaz Lamar are new to me authors and I loved reading their first collaboration, In Case You Forgot. Frederic and Chaz are two black gay men writing about two black gay men living in West Hollywood. This year in the life story left me wanting sequels because I want to read even more about these two interesting characters. Zaire James and Kenny Kane are in similar positions. Coming up on his 30th birthday, Zaire decided it was time to separate from his husband, even though a lot of his family and his friends thought Mario was perfect for him. Kenny, approaching 40, was dumped by Brandon-Malik via text as he was en route to his mother’s funeral. Both of these guys need a reboot. For Zaire that means moving into WeHo--it happens that he moves in across the street from Kenny. He’s got a new job at a social media firm and he’s looking for what comes next. He’s got a family that wants him to find it too--the James Gang siblings--brother Harlem and sisters Langston and Savannah--are always on him to get his life together and find his happy. Kenny, on the other hand, is working on getting his consulting business off the ground since he’s recently finished his doctorate. He’s trying to mostly focus on the business, but he also wants to find Mr. Right. Kenny also carries the weight of having watched his first boyfriend, Jeremy, die after a stabbing. He’s working on his life with some therapy. So what happens in this book? Life. Kenny and Zaire, at times together and at others separate, look for a good date that may lead to more, celebrate birthdays, experience success and failures. The last line of the book’s description captures this perfectly: “...they hope new opportunities, energy, mindsets, and connection will reinvigorate what is missing in their lives--drama and all.” That’s exactly what I liked about In Cast Your Forgot, the slice of life feel. It’s happy, sad, angry, messy and full of great triumph and really bad mistakes. It takes a lot to make this kind of loose plot work, especially since the two lead characters aren’t always together as the year progresses. Frederick and Chaz made it work though. One of the reasons it works is the cast of supporting characters from family, friends, roommates and co-workers. Among my favorite parts of the book was the use of social media to plan their lives and sometimes even to stalk their exes, at times to the chagrin of the friends trying to help them move on. There’s also a Labor Day trip to Palm Springs that was one of my favorite parts of the book because of the realness of how it unfolded and how it tweaked Kenny and Zaire’s relationships. The characters reminded me of Noah’s Arc, a show I loved that ran on Logo in 2005 and then was a movie in 2008. The show focused on queer men of color in various states of life and relationships. Kenny and Zaire would fit right in there. I do want to set some expectations around this book. As you may have figured out, it’s not a romance. It’s categorized that way on the Bold Strokes Books site as well as at retailers. I think that’s wrong. It doesn’t have any of the typical romantic story beats and, most importantly while Kenny and Zaire date for a bit in the middle of the book they don’t get an HEA or HFN as a couple….although the book does end with both characters in good places. If you want a great look at a year-in-the-life of some terrific characters who are trying to get their lives together, I highly recommend In Case You Forgot. And I’d love to see sequels to this book. Frederick, Chaz, please write romances for these guys...

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

The guys open the show congratulating the winners of the 31st Annual Lambda Literary Awards. They also discuss the podcast’s inclusion in Apple Podcasts’ Pride Month recommendations. Jeff also talks about some of the past week’s happenings with his Codename: Winger series and Will asks him what it was like wrapping up the series. Jeff and Will discuss the new Tales of the City series on Netflix. Will reviews the first two books in Piper Scott & Susi Hawke’s Redneck Unicorn Series. Aidan Wayne is interviewed about their three new books out this year: Hitting The Mark, Play It Again and the forthcoming Stage Presents. They also talk about how they decide what goes into the books, how they got started writing, author influences and what’s coming next. Complete shownotes for episode 192 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript – Aidan Wayne This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Welcome, Aidan, to the podcast. It’s great to have you here. Aidan: Thank you. I’m excited to be here. It’s an interesting experience for me. Never done this before. Jeff: Oh, cool. First podcast. Always fun to have people doing their first podcast with us. Now, you’ve had a busy few months of releases and we wanna talk about the most recent one first, which is “Hitting the Mark.” Tell us a little bit about that book and what inspired it. Aidan: Okay. So “Hitting the Mark,” in a nutshell, it’s about a famous movie star named Marcus Economidis, who used to train in martial arts when he was really young and really shy. And that helped him come out of a shell and then he moves. And being in martial arts actually helps him become more confident and he ends up getting a movie role, and that spirals, and then becomes a famous…10 years later, he’s a famous movie star who is also famous for doing his own stunts. Meanwhile, in Marcus’s hometown essentially, his original school – Choi’s Taekwondo Academy – is now run by Taemin Choi. Taemin was Marcus’s kind of assistant instructor growing up. They’re about 10 years apart. So Marcus was 10, Taemin was, like, in his early 20s and Taemin runs the school now. And Marcus happens to be coming back into town for a shoot and he decides to pay a visit to his old school… kind of nostalgia. He lost contact with Taemin when he moved. And so, he kind of wants to bridge the gap again, just like say hi, see what happens. And then they do meet with Marcus being an adult and, you know, there’s kind of an instant connection. The entire book is essentially about them navigating, first, relearning each other because they knew each other for several years, but it’s been several more years since they actually talked again. So they’re relearning who they are as people, especially Marcus as he’s grown into his own self, and that turns into a romantic relationship. And they’re just figuring out how to be in one considering that, you know, Marcus is this famous person and Taemin is a very busy man who runs his own school and takes care of a lot of things. And just, that’s the story basically. I do a lot of character-based stories where the plot is kind of, like, playing the course as opposed to, like, a person antagonist sort of. So it’s kind of like another one of those things for me. Jeff: Okay. And it ticks so many boxes because there’s friends to lovers, and second chances, and an age gap. Aidan: I tend to, when I write, sometimes I have several different things that I wanna include in various ideas. And so, sometimes when I have, like, the base, I’m just like, “Let’s just squish them all together. Let’s just push them all in one thing and see what happens, and if I can pull it off.” Jeff: And you mentioned when we were emailing to set this interview up that this is one of the books you didn’t have to do a ton of research on because… Aidan: Thank God. Jeff: …movies and martial arts, you had the knowledge there. What aspects of your background, you know, play into that? Aidan: Well, I’ve been involved in martial arts for about 20 years now, primarily Taekwondo and that’s the style that I had Taemin doing because I know the most about Taekwondo in Korean style. I technically have my black belt in two disciplines. One is Taekwondo and the other is a mixed type of martial art that I actually ended up teaching. I used to run a school. So a lot of my experience did transfer over into Taemin’s experiences in running a school and dealing with students and various endeavors that are required. And with movies, I actually majored in media production in college. I was on movie sets a lot both behind the camera and also growing up, I kind of dabbled in acting and I’ve been in front of the camera a lot too including on some big sets. Michigan used to be a pretty big movie hub before the tax thing happened and a lot of places moved away from it. And I was actually on a few different, like, SAG films. So I got to kind of be both in front of the camera and behind the camera. So learning about that aspect was…It was fun to basically shove as much knowledge as I could, especially the martial arts into one book because I have such a love for martial arts that it was like, “Let’s include inside jokes and inside knowledge. And I’ve never had to spell this Korean word in English before. So I have to probably look that up.” And fun fact actually, I’m not gonna spoil anything, but one of the plot points is Taemin working towards the Olympics. He’s qualified for the qualification and that entire piece is actually based on a co-worker of mine I used to work with who did qualify for the Olympic matches. Jeff: Incredible. You did stuff a lot in here in terms of all of your knowledge kinda went into this book. Aidan: Yeah. It was kinda, it was a nice break. I still had to do research obviously because I had to, like, fresh some things and again, like, Korean, making sure that I got that right. But for a lot of it, like, I have another book that I released late last year, “His Two Leading Men,” which takes place in New York with a Broadway star, and I’m like, “I like Broadway, I can just write about plays, that’s fine.” No, I ended up having to map out the entire city to figure out distances to whichever…I’m crazy…whichever restaurant he’d like to go to, which is closer, where is laundromat was. Like, I’m absolutely ridiculous when it comes to stuff like that. Nobody is gonna notice but me. But, like, I care. Jeff: But the native New Yorkers might. And so, it matters. Aidan: Yeah, yeah. Jeff: I have stopped myself of books going, “That’s not right. I know where that is and that doesn’t work that way.” So you do work Michigan into a lot of your books. “Hitting the Mark” is in Michigan. “Play It Again,” which we’ll dive more into in just a second, has a Michigan element simply because you have somebody sending Dovid, the main character, some Faygo Red Pop and some other Michigan treats, some Mackinac fudge included. Obviously, you live in Michigan. Is it something you try to work into the books, a little Michigan angle? Aidan: Kind of. Half of it is ‘write what you know’ because I’m thoroughly uncreative when it comes to that and it’s way easier to just, like, I don’t have to make something up, I don’t have to do more research. I just can set it in Farmington Hills or wherever it is. But sometimes it’s because I have, like, certain places in mind or I want to include certain things like, with Dovid receiving a care package, I wanted to make sure that I had a care package that at least was state-based and was really cool and could include especially a lot of food because a lot of…Dovid being blind, a lot of his things are food-based, it’s part of his schtick. So he reacts to taste and stuff. So knowing that I have my own experience with various Michigan cuisines and snacks and stuff, I could include that pretty easily and know that it would ring true but also be kind of funny. And even if the person didn’t necessarily know what things were, it would still, like, be something that they could get. Jeff: Speaking of “Play it Again,” that I reviewed back in episode 186 and really, really loved it. It was like the book I didn’t know I needed at the time. Aidan: Thank you. Jeff: And it’s quite different from “Hitting the Mark.” What was the inspiration behind this tale of two YouTubers who managed to find love even though they live half a world apart? Aidan: Well, going back to my ‘I have various ideas, but squish them all together into one sometimes.’ I really, really wanted to showcase a blind character. A lot of the characters that I do showcase are disabled in some way or have, you know, different aspects of their life that aren’t typical, you know, part of normative parts of society, etc., etc. And I apologize if my verbiage isn’t the best. And I really want to showcase a blind character, but obviously, I didn’t wanna fetishize that I wanted him to be successful and happy, and not be just blind as his character if that makes sense. And I thought YouTube would be a fun angle for that. And on the other side, I really wanted to focus on, like, a Let’s Player because I thought that it would be fun to try to, like, figure out how to write that because it’s so much narration and video-audio-based. And I like playing and like, “Can I do this? I will see if I can.” So making it a long-distance relationship was also kind of something that sort of happened because long-distance relationships, specifically internet-based ones, are very important to me because I have several relationships that started being internet-only and I consider a lot of these people some of my closest friends and I’ve met many of them in person now. One of my friends, I’ve only ever met them once, and it was in our first meeting ever…we then spent two weeks together, but our first meeting ever was in Narita Airport in Tokyo where we both flew separately and then spent two weeks in Japan together. So, like, yeah, there’s a lot that can come from internet relationships and I really wanted to showcase something like that too. Jeff: And I’d imagine here that the research was more than “Hitting the Mark” because you needed to make sure that Dovid was portrayed in the way that you wanted to where, you know, he wasn’t necessarily defined by the blindness. Aidan: Oh, yeah. I do extensive research whenever I write, especially disabled characters, because, you know, there’s so much misinformation out there and it’s so easy to fall into the trap of what the media has portrayed a person to be like or to do as opposed to actually reading experiences and watching experiences about, you know, real people. I kind of posed this question to myself on Twitter a while back, but it was basically, how does one write about a successful blind YouTuber? Watch a lot of successful blind YouTubers basically. So I watched a lot of, like, “The Tommy Edison Experience” is a man who is blind and he has a lot of Q&As; on YouTube. A lot of his videos are older and he’s an older gentleman. But it was still, you know, very informative. He has, like, an episode about cooking, which Dovid is the chef of his little family where he lives with his sister, Rachel. So it was interesting to, like, make sure that I was, you know, portraying his ability to do that correctly and, like, different tools that he’d use. Molly Burke is also a YouTuber that does makeup and fashion. But how she interacts, you know, with her audience and interacts with herself, and the things that are important to her – her experiences – because she does talk about that as well. It was very important. There’s a Tumblr called “Actually Blind” that did Q&As; and did a lot of commentary on different things and responded to different situations where, you know, there’s one impairment affected daily life that was not considered. And “Actually Blind” was a huge help in doing a lot of research because even when I didn’t actually ask the question myself, sometimes they just talked about things that I hadn’t thought about before. So that was a really good thing to notice. Like for instance, they had a post about the fact that the face touch thing in so many books and so many movies is absolutely ludicrous and no blind person really does that. And because it was made up by a sighted person who thought that it was kind of like romantic and intimate to have the blind person, like, touch the other person’s face to see what they look like and “Actually Blind” was like, “No, no. Uh-uh.” So it was something that I didn’t include then and I might have if I hadn’t read something like that. Jeff: The research is oh, so important. Aidan: Absolutely, absolutely. And I do a lot of sensitivity readers too. I have a short story that is going to be coming out probably in October, because I’m spacing it out a little bit, where one of the main characters is in a wheelchair. So luckily, I’m like, “Hey, sibling, I’m gonna ask you some wheelchair questions.” And know about how my experiences in, you know, living with somebody who uses a mobility aid and all that. So proper portrayal is really important to me. Jeff: And you have still yet another type of story coming out with your upcoming YA novel, “Stage Presents.” And I’m fascinated by this way because you’re taking us to Disney College Program. Do you have experience in that or was that a ton more research? And of course, what is this book about because it sounds just delightful? Aidan: Oh, well, thank you. I hope it is delightful. I hope people enjoy it. And to your question, yes and yes. I did experience, I did do the Disney college program many years ago, but I also did do a lot of research for the story in part because, you know, Disney updates and changes things. So some of the things I had to look up were the current menus and stuff because, again, it’s like a tiny little detail that only I will notice but I cared about. But I also had to make sure that I was getting details right in terms of characters because one of the main characters, Ashlee, with two Es, is a Disney princess literally. I did a lot of research into behind the scenes of that a little bit. I watched a lot of ex-princess interviews and posts about the experience of being a character performer. I didn’t have a lot of experience in that capacity. I knew some people who are friends with characters while I was in the program and I did ask, you know, I did learn about it that way. But princesses, I had to learn a little bit more. And, oh, yeah, what the book is about. Two girls who both get onto the Disney College Program and end up his roommates. One, Dana is a kind of, you know, calm, cool, collected, very down to earth, logical girl who is going into international business, she’s excited about working in a Fortune 500 company. She’s looking forward to living away from home. She’s trans. So, you know, that’s just another aspect of who she is as a person and she’s kind of like not sure about how she’s gonna get along with people. But she kind of has the mindset of ‘judge people before they judge you’ sort of thing because of past experiences. Meanwhile, on the other side, Ashlee, with two Es, loves Disney…I know, it’s a very important detail. She loves Disney, she’s a Disneyphile, she loves all the movies, she loves all the songs. She gets cast as an actual Disney princess. This is her dream come true. She’s been dancing since she was little. So one of her goals is to be a parade performer Disney princess, essentially, and she’s super excited. She’s from good old Southern Georgia and has never really, you know, met somebody who’s not exactly like her and her little clique, you know, popular, excited, happy group. So she doesn’t really know what trans means and she was born around…she knows what the internet is, but still, it’s different from knowing and meeting and, like, actually talking to somebody and interacting. And then so, Ashlee is kind of ignorant and Dana is kind of standoffish, and they hate each other. A good portion of the book is just them hating each other, and eventually, of course, a couple of different things happen and it turns into a begrudging friendship, which turns into actual friendship, which turns into more. And it was, you know, writing the evolution of enemies to lovers, which is something that I hadn’t done before really, and integrating different aspects of their situation and being roommates and living in such close quarters and, like, what constitutes that kind of relationship too, especially while you do not like each other and then as friends, and then, you know, once you’re more intimate as well. So that was, like, a whole encompassing aspect of the story itself. Jeff: And now, it sounds even more delightful than when I read the blurb. Aidan: Okay. Good. I had a lot of fun. I like my stories, which is, you know, a fun thing to be able to say because a lot of them I think, just kind of get defined as ‘fun’. There are obviously elements of angst and stuff and, you know, negativity that happens, but I have fun, you know, writing them. I hope that people have fun reading them. Jeff: What got you into writing and M/M romance in particular? Aidan: Well, I’ve always been a storyteller. My dad also, when we were kids, he would make up bedtime stories. We got read to a lot too, but he would make them up. So I grew up with the elements of imagination as something that you could play with and figuring out different elements of what characters could do. Really, you know, being totally honest, fan fiction. I was really, really interested in “Elfquest” as a kid. It is a fantasy novel by Wendy and Richard Penny. And man, I was an “Elfquest” fan. I read and actually own, I’ve collected almost all of the books and volumes and made up as a tiny little 9-year-old, self-inserts in my head as being an elf with such and such power, and being part of that self-insert stuff. And as I got into more media growing up, I really enjoyed reading and writing fan fiction because it was a way to interact with something that I enjoyed so much past where the media itself went. And sometimes things happen that you didn’t like. So you could make them better by writing it yourself or reading it by other people who did a good job or further exploring the world that had already been created with characters you already liked. And from there, it was kind of like, “Oh, I could do this with my own characters and make whatever I want to happen, happen. What? Oh.” And the kickoff was when I was, I don’t know, like, 15, I participated in my first NaNoWriMo and that was the first, like, write a lot of words and also write them really quickly. So you can’t think too much about what you were doing, you know, “wrong.” I wrote 50,000 words in the 30 days. And man, I still have it and it really portrays what I was into, what I was learning, and what I was experimenting with as a 15-year-old because it is a lot of stuff. And I really enjoyed doing that and I kind of just kept at it. And eventually, I had a friend who I really admired, Mina MacLeod, who was also a writer that I was friends with at the time. And she talked about an anthology and encouraged me to also, you know, submit a story, a piece, and I did. And we both got in and I still have the copy of the book, but we’re both in the anthology, both me and this writer that I really admire. And, like, that was really cool. And from there, I went, “Oh, wait, publishing is possible, that this is a thing that actually can happen to, like, real human people as opposed to just authors who are these untouchable people on pedestals.” So my next book that I wrote was written with publishing in mind. That was “Loud and Clear.” And it was technically my first original, original piece. Speaking of smooshing everything together at once, that book is about a man who is so dyslexic, he is essentially illiterate and a businessman who has a stutter so bad that he is a selective mute, falling in love and entering into a relationship. So you got someone who can’t read and someone who communicates through writing and I was like, “Let’s just make this as complicated for myself as possible. That’s a good idea.” But, you know. Jeff: Yeah. For a first book, you took on a lot there. Aidan: You know, it suffers from an overuse of italics, but it’s still something that I really appreciate that I did as a writer. I really like it. I had a lot of people really like the fact that I, you know, portrayed people that way, and of course, it does focus on non-normative people with disabilities and challenges in, you know, typical normal society. The illiteracy was actually based on a friend of mine who is illiterate. His dyslexia is so bad, he is effectively illiterate. He’s also an engineer. So, you know, it doesn’t stop you. It doesn’t have to stop you as long as you have the right elements and encouragement and resources. And that’s what a lot of people do struggle with. Like, he had to be homeschooled because his school that his parents had put him in originally were like, “We don’t know what to do with this child.” So being homeschooled allowed him to learn and actually grow and actually learn. Jeff: I have a suspicion a little bit where this next question at least will go a little bit given the “Elfquest” things, but what authors and genres do you tend to read? Aidan: Basically everything, but gore horror to be honest. I really enjoy contemporary pieces. I like fantasy. I really like nonfiction. I love learning stuff. This is probably not a surprise considering my need for research, my favorite author in the entire world is Terry Pratchett. That probably will never change. The man was absolutely brilliant and his ability to tell stories, and well-rounded characters, and development in plot, and his care in structure, and how he’s able to tie things up neatly with, you know, no questions except for like, what could happen next? He’s absolutely amazing. I really admire him. If I like a tenth of his ability to just, like, story weave, I’d be content in my ability to create. One of the other authors I really enjoy, he’s a very lesser known author, but Barry Hughart. He wrote “Bridge of Birds.” That is a Chinese fantasy mythology story, which basically happens in a historical China, but is written as if mythology was real. And he’s also, like, a very unknown and should be more known author for what he’s able to do with creativity. Other books that I appreciate, I enjoy a lot of Tamora Pierce’s work, especially the “Keladry” series because I really enjoyed her portrayal of a woman, a girl growing up and wanting to be a knight and fighting and dealing with a lot of the prejudices that come from, you know, girls trying to do anything that boys like to do. So, those pieces and she also is essentially…she’s written as not really interested in amorous connections, so to speak, and Tamora Pierce did end up saying that she did write her as asexual even though she didn’t, like, really know the term at the time. So that was really appreciated. Oh, that dovetailed a lot. M/M romance, yes, okay. There is a lot of het romance out there and that’s fine, you know, it’s got a market for a reason. It can be very well done. Me personally, it’s done by other people well and I gravitated more towards queer characters. M/M romance was easier for me to write because it was easier for me not necessarily to identify with the characters, but write about them in ways I wanted to, you know, with gentler portrayals and different effects. I wouldn’t say that I particularly write, like, alpha man male sort of things because it’s not really something that appeals to me personally as an author or as a person. I like people who are settled into themselves and know who they are and may be confident, maybe inconfident. For instance, in “Play it Again,” Dovid is a very confident individual who knows who he is and is really happy with himself. And Sam is much shyer and he’s wracked with anxiety all the time. But they’re both human. I like portraying clear people as human and I think that’s why I gravitated towards it first. I’m not super sure why I write M/M mostly. It’s just because it is a little bit easier for me to…I guess, it does come back to identification. I’ve written one…I have one published female-centric romance, which I do really like. It’s called “Making Love,” which I think is one of my favorite titles ever. It’s about a succubus and cupid falling in love. I was very proud of that, and it’s adorable. It’s very cute, it’s very loving, it’s really soft. And Carla, the cupid is just, like, made of cotton candy and love, sweet, and is really happy and bubbly. And Leeta, the succubus, is kind of cool and had reason to put up a lot of walls. Carla melts her heart and it’s so cute. It’s very silly, a lot of my reviews were like, “It’s cute, but cheesy.” And I’m like, “Yes, that was exactly what I was doing.” It’s called “Making Love,” what were you expecting? And then, same thing with “Stage Presents,” both the main characters are female. Dana is trans. I really enjoy portraying again, like, different aspects and different facets of queer people being human. They make coffee and they’re grumpy, and they might have disabilities or other challenges in life. And they also like stuff and are bad at things, and aren’t just, like, one cutout of a representation that, you know, people have one idea about. I like character-driven stories. Queer people deserve happy endings too. That’s the other thing. Jeff: Yeah. Absolutely on that one for sure. So we know “Stage Presents” is coming up here soon. What else is coming for you this year? Aidan: Well, I’ve mentioned it briefly, I have a short story that I had been kind of working on off and on. I was calling it “Baker Story” on Twitter and I did name it “Not So Cookie-Cutter” or something terrible like that because every single one of my titles…you may or may not know this, every single one of my titles are puns or play on words because I’m ridiculous and I love it. Yeah. So the book, “Bakery Story,” is called “Not So Cookie-Cutter.” I’m probably going to release it around October. It’s about two POC characters, which I did get sensitivity readers for because that was important to me. Jerel who is a baker at like, a cafe/coffee shop and Rafi who is a client who falls in love with Jerel’s pumpkin cheesecake essentially, and romance. They’re cute, it’s cute. One of my favorite things about the story is Rafi uses a wheelchair and Jerel is so smitten by Rafi that he doesn’t notice for, like, two chapters because Rafi is sitting down when he’s, you know, at the cafe and Jerel is just like, “Oh, my gosh, this handsome, amazing human being who is talking to me, like, he thinks I’m cute, okay.” And then, like, when Rafi actually, like, moves in front of him and he rolls away, Jerel’s like, “Oh, my God. I’m an idiot. This is fine. I’m an idiot.” So… Jeff: Nice. That will be one to look forward to this fall. Aidan: Yeah. I think, you know, it’s cute, cute and dumb. That’s kind of my mode. Jeff: What’s the best way for everyone to keep up with you online? Aidan: Twitter is mostly what I use, @aidanwayne is my Twitter handle, user name thing, and that’s primarily where I am. I have a website too and if you go to my website, there’s an option to sign up for my mailing list and mailing list is kind of how I send out information about releases to people. But I don’t like inundate people with mail. It’s just like, “I have a release, yay. Here it is, yay.” Jeff: Cool. We will link to those as well as all of the great stuff that we’ve talked about in this interview. Aidan: Cool. Jeff: Aidan, thank you so much for hanging out with us. It has just been a delight talking to you. Aidan: Yeah. Absolutely. Thank you for having me. Again, I’m ridiculous. So I appreciate being able to be ridiculous on a podcast. That’s cool. And, yeah, this was a lot of fun. Thank you so much. Book Reviews Here’s the text of this week’s book reviews: Seriously Horny (Redneck Unicorns #1) by Piper Scott & Susi Hawke and Dangerously Horny (Redneck Unicorns #2) by Piper Scott & Susi Hawke. Reviewed by Will.Seriously Horny Unicorn shifter Isaiah is pure white trash. How do we know? We’re introduced to him as he’s settling in for the evening, in his trailer with a bottle of his pappy’s moonshine – but he’s also an expert tracker. He’s tasked with finding a missing teenage dragon shifter. He runs into the kid’s college age brother, Eric, an irresistible dragon omega. They go to search together for Eric’s brother. One night, in a motel room they give in to their desire, and trust me, the scene lives up to the book’s title. Eric has the power of second sight, kind of like Faye Dunaway in Eyes of Laura Mars, and he ‘sees’ where his brother lays injured. Isaiah and Eric find him and bring him back to the dragon compound where he can heal from his injuries. Eric is with child after his night with Isaiah, and months later we find our heroes happily in love with the beginnings of a new family. In Dangerously Horny, Unicorn shifter Bo Luke finally gets up the nerve to tell Mitch just how he feels. But broken-down dragon is a less than ideal match for someone so young. The rejection hits Bo Luke hard and he runs off, straight into the clutches of a crazed woman who has uncovered the secret of the unicorn clan, and desperately wants to touch Bo Luke’s horn – and yes, that euphemism means exactly what you think it means. Mitch and some of his dragon buddies are sent to find Bo Luke. They rescue him and subdue his kidnapper. Because this is a paranormal shifter Mpreg romance, omega Bo Luke finds himself in an uncomfortable situation, and alpha Mitch is the only one who can scratch his particular itch. They fuck and it’s hot and amazing and (of course) totally magical. Mitch’s misgivings were unfounded, they are now fated mates. While waiting for their child to be born, Bo Luke’s stalker escapes custody and attempts to kidnap her unicorn obsession once more. In an action sequence that I thought was particularly bad-ass, Mitch and the entire dragon clan literally reign down fire upon her, rescuing Bo Luke once again. The story wraps up with a hilarious scene in which our heroes experience a very memorable wedding/birthday. The covers of these books tell you everything you need to know. The hot cover models clue you into the sexy times ahead, while the titles, which are decidedly camp, tell you that these romances also about the humor – humor with heart. I loved both of these stories and think they’re a fantastic way to kick off the new series. While ‘Redneck Unicorns’ is a continuation of the author’s previous dragon series, they stand alone just fine.

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)

Jeff discusses a deleted scene he’s offering this week from his upcoming book Netminder (Codename: Winger #4). He also recommends The Queer Creative Podcast. Will and Jeff discuss the second season of Netflix’s She-Ra and the Princesses of Power as well as Pose, which has just arrived on Netflix ahead of the new season coming to FX in June. Jeff reviews Queer as a Five Dollar Bill by Lee Wind. Gail Carriger talks to Jeff about her new novel, The Fifth Gender and some of the interesting stories about its creation. They also talk about how Gail went from archeology to writing romance, her process for world building and her travel podcast called The 20 Minute Delay. Complete shownotes for episode 189 along with a transcript of the interview are at BigGayFictionPodcast.com. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish Hank Edwards and Deanna Wadsworth’s new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Welcome, Gail, to the podcast. Gail: Hello. Thank you for having me. I’m super excited to be here. Jeff: I’m so glad we finally got you on the show because I’ve been, you know, reading since back with “The Sumage Solution” and it’s like, “We gotta get Gail on. We need to get Gail on.” Gail: I am delighted. I am a devoted listener and so I’m quite honored to finally get to be here. It’s great. Jeff: And you’ve got a book coming out or you’ve just had a book come out actually, “The 5th Gender” just released. Gail: I did. Yes, “The 5th Gender,” it’s my like crazy, ridiculous, silly, happy yet cozy murder mystery on a space station with an alien with five genders and tentacles and purple. Jeff: You don’t often get cozy mystery space station together in one package. Gail: It is…it’s great. It was totally one of those spontaneous, I had like a strange thought/dream/idea to do this. And a bunch of us were joking on Twitter about the craziest mashups of genres we could come up with and somebody was like, “Barbarian noir,” and so on and so forth. And I was like, “Well, I wanna do space station, cozy mystery.” And then I started thinking about it and then it happened. Then I was like, “Oh, okay, I’ll write it, I’ll write it.” I was supposed to be writing something else, of course. But sometimes I succumb to the lure of the ooh, shiny. Jeff: And it was a purple shiny too. So how could you resist that? Gail: I could not. And he’s adorable, the alien character. And I, you know, I have a background as an anthropologist. I have an archaeology…couple of archaeology degrees. And so I just love the way if you’re doing an alien character, you can comment on human social structures and culture and interactions. And so I might’ve had a little too much fun with that. Jeff: Well I was actually gonna get into that. I’ll hold that. Because we should at least tell folks, because I want to talk a little bit more about the origin story on this because you wrote about it. So just like, “I had this idea in the middle of the night, and then I tweeted it, and then it was a story,” which I love, but then there’s the fact that you went away to a retreat and worked on it and had to talk to other people about it while you were writing it. Gail: Yes. So for those…I should preface this by saying that for those who don’t know, I have two names I write under. So I write under Gail Carriger and I write under G. L. Carriger and the G. L. stuff has a much higher heat level. So it’s super sexy. And this book, “The 5th Gender” is a G. L. book. So warning for anybody who doesn’t like nooky because one of the things I realized through the course of that particular writing retreat was that if you’re writing about a species with five genders, human curiosity wants to follow them into the bedroom to see what it’s like down there. And so I thought about trying to kind of clean it up a little bit and it just…it didn’t work. So I was like, “Okay, we are going into that realm.” So I was supposed to go on this retreat and write something else entirely, and instead I just spent the entire week writing this book. And one of the funniest stories from that was me being like, “Oh shoot, what does alien jizz taste like?” Because we all know, at least we do if we’ve been reading my San Andreas Shifter series that wizard or mage jizz is fizzy and werewolf is spicy. And I was like, “Well, what do aliens taste like?” And this meant that I literally had to go and you’re never…on a retreat, you’re never supposed to disturb the cooks in the kitchen. But I was like, “If there was ever a question for cooks, this is it.” There is a crazy author running into the kitchen in the middle of them making shepherd’s pie and being like, “Oh, you guys, what does alien jizz taste like? Debate.” So we had a long debate about it and we finally decided, and you’ll have to read the book to find out. Jeff: Yeah, I wasn’t gonna ask you to spoil that, but I do have to know what exactly did the cooks make of this question? Gail: The cooks were quite game actually. I think they were pretty charmed because normally like they’re doing their art form and we’re doing our art form and never the twain shall meet until meal times. So it’s really rare for one of the authors to actually want the cooks’ help on something. So I think they were kind of pleased to be asked. Jeff: That’s very cool because some of them might have been like, “I’m sorry, what?” Gail: Oh, they know what I write. We’ve been going for a long time with the same cooks for a while, so. Jeff: So this group knew you so they weren’t necessarily surprised by… Gail: No. Well, it was a little out of the blue. I haven’t been writing the super sexy stuff for very long. Like normally my questions are like, “What’s the most ridiculously named, you know, Victorian dessert you can think of,” kind of thing. But yes, it was a little different from my usual questions. Jeff: And tell us what this book is about, this cozy mystery on a space station. Gail: Well, the tagline is an alien race with no word for murder has a murderer aboard their spaceship. And essentially the galoi are the aliens in question. And they are these purple…they’re these adorable sort of purple tentacled kind of, you know, High Elf, slightly looking alien creatures. And they are super isolationist. And the only thing that humans know about them is occasionally they will kick one of their genders. It’s always as one of the examples of the fourth or fifth genders and they’re kicked off and they’re in exile, and those galoi, which is the name of this alien race, go and live amongst humans. And humans actually adore them because they think they’re like sweet and cute and adorable. And they have no…they’re pure exiles. So they have no national allegiance, they have no planetary allegiance. And so they make really great attaches. They’re kind of really kind of comforting and lots of different alien races like to be around them. So they often become attaches to like ambassadors and stuff. So a lot of space stations….space stations consider it really lucky if they get one of these. And the main character, Tristol, he’s one of these aliens and he has a mad crush on the human security chief/detective that’s onboard the space station named Dre. But he doesn’t really get kind of like human flirtation and courting rituals. So he’s sort of…the book sort of starts with Tristol trying to figure out what cats are and why you would wanna keep them as a pet because he’s been asked by some human friends to cat sit. And then, of course, the cat escapes and hijinks ensue on the space station because what happens when the cat gets into zero gravity. Nobody wants to find that out. Anyway, and then the galoi are like super xenophobic, so they never reach out to humans. And then suddenly a galoi ship approaches his space station, which is crazy in many, many ways because they shouldn’t be approaching a space station that has an exile aboard it and they never talk to humans anyway. And they have this incredibly complicated non-pronoun language that kind of indicates status and has to do with all of these different genders. And so the humans are kind of panicking and freaking out. They don’t want a war. They don’t know what’s going on. And the spaceship basically says, you know, “We have a murdered galoi and we don’t know what to do. We don’t have security, we don’t have murder investigations. We don’t. So we came to you, violent humans, to figure this out for us.” And of course Dre, the human love interest is the detective. So he and Tristol have to team up because he needs Tristol’s help to explain how the galoi work. And so the two of them gonna figure out who done it and that’s basically it in a very large nutshell. Jeff: How did you go about creating the galoi? I mean, five genders, no term for murder. There’s like so many things that kind of click into this. Is there like…? Gail: I just, so like I said, I have an anthropology background. I mean, archaeology is blank, so obviously the biology and skeletal structures and things is what I mostly studied via anthropology, but you get a lot of like gender studies and cultural representations of gender and all that sort of thing as part of an education in the United States if you do an archaeology degree. And so it’s always been super, super fascinating to me. I have a minor in classical mythology with a focus on gender. It’s just something that has interested me. It’s really hard to tease out in the archaeological record. It’s prone to misinterpretation by archaeologists and historians and anthropologists. So there’s a sort of storied history with our own relationship from a scientific perspective with understanding gender. And so I just took a lot of that both kind of my education and, you know, how the world now is changing. I spent far too much time on Tumblr, so I have a lot of like non-binary and gender fluid and gender queer fans. And so I’ve just been kind of reaching out to friends and acquaintances. One of my best friends in the world is a bioethicist and a medical ethicist. And so she deals with training doctors in how to talk to people appropriately about gender. And so I’ve had all this sort of stuff messing about, and I was like, “Well, a way for me to explore this and have this kind of conversation with myself and the world is through an alien lens.” And so I just…I love thought experiments, and I was like, “So what if we have a race with five different genders and how would their language evolve? How would their culture evolve? How would they treat each other?” Like all of these, you know, archaeological things to think or anthropological things to think about. And then how would humans, even future humans, react when encountering that? And so that’s kind of where the conception started. And then I just made them purple because I like purple. Jeff: Why not? I’m a big purple fan too. Was there a lot of research kind of building this? Gail: Yeah. I actually have multiple blog posts that either I’m releasing them right now or I’ve just released them recently, speaking from the past into the future. But I have a bunch of blog posts about like a bunch of the research that I did and like some book recommendations and stuff like that, both from a fictional perspective and a nonfictional perspective and different blogs and stuff like that. But I like that. I like researching a lot. I try not to rabbit hole too much because the point is to write the actual book. So mostly what I did is I did that intensive week where I sort of just vomited forth this whole book. And then I went back and like teased it apart and looked into different…almost as…I almost treated it a little bit as if it were a nonfiction piece to go back and see what sources do I need to look up, what like different pronoun terms might be being used in hundreds of years, you know, by humans. That sort of thing. And it’s…since both the humans involved… I try to be complex in my races, whether they’re werewolves or aliens in that like…and to not either dystopian or utopianise either race, either humans or aliens. So both races still have issues. Both are still dealing with how the cultures have evolved and all of that sort of thing. So I’m not setting the galoi up as like the perfect model of a possible future. They have a different evolution, a different model. And they’re merely a vehicle for which we can examine perhaps some of our own biases and prejudices now. And that’s getting very, very serious because mostly what I want my books to do is make you happy and cheerful and be excited, delighted. And if it makes you think a little, that’s great. But really I just want to make everybody happy and hopefully Tristol will do that because he’s delightful. I love him. Jeff: What kind of, I guess, beta reading did you do to see how your various fans handle the gender discussion? Gail: Well, I have trans and gender queer and gender bending characters already, both in my main universe and in my traditionally-published books and in all of my…like my independent and my self-published works and in my novellas and stuff. Some of the main characters, some of them side characters. And so I know that they’re open to it, and I also know that the one that, you know, for lack of a better term, I have like a queer-centered, progressive kind of comfort food brand or business model or whatever, however you wanna explain it. And so I feel like most of my super fans are gonna be excited because what they want from me is that comfort, is that sort of upbeat, fun, slightly fluffy, slightly thoughtful, but ultimately, you know, everything’s gonna be all right. I’m never gonna depress you. There’s never gonna be like scenes of torture. It’s never gonna be angsty, you know, all of those things. It’s always gonna be delicious, I guess. Jeff: I like that as a term for a book. That’s just really fun. Gail: Yeah. It’s just gonna be tasty. Yeah. So they know that and that’s the part that they trust and generally I feel like they’re pretty open minded about how I’m gonna go there and explore that. I don’t think I would’ve done this book, you know, five or six years ago because I wasn’t sure. I had to kind of test the waters with the San Andreas books and some of the other stuff. But I think they’re pretty open to it. I don’t know. You never know. We’ll see how everybody reacts. Yeah, so I mean, and I have beta readers and some of them have read it. I was more careful with this book in making sure that like I had sensitivity, what I call delicacy readers. So people within kind of the gender nonconforming community, again, for lack of a better term. That was more important to me really. I don’t wanna offend, although, you know, everybody’s opinion is their own and everyone is entitled to it. So I’m sure if you come to any book with the idea of being offended, you’re probably going to be unfortunately. So, but I did put essentially a naked purple dude on the cover as a kind of like, “Be aware, there’s gonna be sex in this book. We’re gonna go there. We’re gonna go far out there.” Jeff: It’s cozy with sex and it’s funny and it’s sci-fi. It’s got a little bit of everything in it. Gail: Exactly. Jeff: Do you think you’ll revisit this later as like as a continuing series? Gail: I’d love to. Actually, I have another murder mystery and like I don’t consider myself like a mystery writer at all, but I have this thing as a writer where I don’t write a book until I’ve had what I call the epiphany, which is I need to actually see a scene with characters in dialogue. And it might not necessarily be the first scene or whatever, but until I see that I have that crystal moment, I don’t feel like I can write the book. So I have a lot of books that I’d like to write, but I’ve never had the epiphany with. So they’re just sort of sitting there. And I’ve had an epiphany for a second book in this series with Dre investigating another murder and Tristol still there and everything. But I don’t know how people will receive this one, so I don’t know if I will write that one, but it’s definitely there percolating already. So it’s a possibility. Jeff: It’s a possibility. Gail: Yeah. And the universe on the whole, because it is a science fiction universe, actually does have another, of all things, young adult series that’s set at it that’s kind of been on the back burner for a really long time which kind of has nothing really to do with this series except that the same conceits in terms of faster than light travel. And human…like colonization and planetary evolution are the same. And there’s like a couple of crossover alien races, but that’s about it. But it is the same sort of basic far future. Jeff: If you’ve got the universe, you might as well keep using it. So you don’t have to just keep reinventing the wheel. Gail: Precisely. Yes. That’s my feeling. Jeff: What do you hope readers take away from this romp? Gail: Well, like usual, I just want them to be like… My favorite thing is somebody writes to me and says, “You either humiliated me because I was laughing loudly on public transport,” and I’m like, “Yes.” “You kept me up all night.” “Yes.” Or, “You just left me with a big smile.” So that’s really what I genuinely want is a big smile on people’s faces. But it would be nice if people who read it thought a little bit about…a bit more about gender and how we intimately link biological sex with gender and that perhaps that’s not necessarily the…I don’t know, ethical thing to do – that perhaps gender is in fact a social construct. Or cultural construct. It’s something that anthropologists just accept. Like if you’re an anthropologist, you just accept that as a fact. Like we know, we have seen all of these different ancient and modern races or cultures with varying different interpretations of genders and it just…I don’t think it would ever occur to an anthropologist to like not be like, “Yes, gender is cultural,” but it seems that in the world today that isn’t an accepted principle. And so I guess, if anything, I want people to kind of get it, to maybe think a little bit about pronoun use and all that sort of stuff, I guess. Jeff: Now, as both Gail and G. L., you run across a lot of genres. You’ve got your urban fantasy, you’ve got some paranormal. Now you’ve got cozy mysteries in space. Comedy definitely cuts across all of them. Is there a genre you like most? Gail: I would say I have wheelhouses more than anything else. So there’s a podcast called “Reading Glasses” that talks about as readers we tend to have wheelhouses and if you read heavily in romance, you define those often as tropes. You know, like, “I like the enemies to lover,” or whatever. But a wheelhouse kind of has other things. So, and I would say that there are definitely wheelhouses I gravitate to. So I always write the heroine’s journey. I never write the hero’s journey regardless… Again, this is the gender thing, right? Regardless of the biological sex or stated gender of my main character, they’re always heroines’ journeys because a heroine’s journey, it doesn’t matter who’s undertaking it. So I would say that is one of my things. I always do ‘found family’, and I realized recently I had this big revelation that one of the reasons I strongly gravitate to reading gay romance in particular is because found family is a really popular trope within gay romance for obvious reasons because if you come to the queer community, it’s usually partly found family that brings you there because real family rejected you, at least often did when I was younger. So yeah, and I just love that as a trope, for lack of a better word. And so I have found family in my books all the time. I tend to have extremely strong female main characters except when I’m writing gay romance, of course. Yeah, and lots of queer. I was thinking recently that a slogan I really embrace would be queer comfort because I feel like that’s kind of in all of my books even the books that have heterosexual main couples. It’s really hard. At this juncture, I guess you could say that I trust my readers enough to relax and just write what moves me. I wouldn’t have written this book if I didn’t think at least some of them would enjoy it. I mean, what a privilege and kind of a blessing and a joy to get to do that. But it has been 10 years. So it did take a while. Jeff: And you mentioned that you’re not known for mystery, certainly. So you’ve taken this turn now to at least explore it once. Are there other things out there like, going after and trying to write a mystery, that are still things you want to do, things you’re looking at towards the future? Gail: Absolutely. There’s always… Like I adore high fantasy. Obviously, I’m really into world building. And so like I have a young adult high fantasy. It’s actually techno fantasy, kind of like the Pern books or “Darkover.” And so, you know, I’d like to do that. There’s a bunch of stuff that I kind of am excited and interested, and I’m a pretty voracious and pretty wide reader. So I think that makes you, generally speaking, a relatively wide writer. I think it’s unlikely I would ever break the trust contract that I have with my reader base and write anything dark. I certainly would never write anything gritty or gruesome. I don’t like to read that, so I’d never write it. And I think I’m out of my dark phase now that I have left high school. I don’t do the really kind of dark or angsty stuff. I was thinking about contemporary recently actually. And I don’t think I could write contemporary. The moment I start to think about writing something that’s just a contemporary romance or like women’s lit or even something, you know, Heaven forfend, like proper lit fic, it immediately just goes fantastical. I can’t, I have to inject. And if I were to describe myself as anything, it is, you know, science fiction and fantasy rooted, I like the world building a lot. And so I think it’s unlikely that I’ll ever write something that doesn’t have at least that as part of the component. Jeff: So how did you go from studying archaeology and getting these degrees to now becoming full-time author, writing all these books? What was that path? Gail: Oh my goodness. So I’ve two master’s degrees and I was working on my PhD and I always thought I would be an academic. I genuinely love archaeology. I’m one of those incredibly lucky people who left one career that she adored for another career that she adored. So, you know, tragedy of choice. And I was about to do my defense and I was about two years out which would have been my thesis years finishing my PhD. And I always wrote. I just grew up on what essentially amounted to kind of like a hippie commune kind of thing, and surrounded by artists. And the only thing I had learned really from that is that artists never make any money. And so being an author was really a bad idea. So I was like, “Okay, I’ll be an academic because, ooh, profitable.” At least it’s quasi reliable, right? But I always wrote, I just had that need. It’s kind of like breathing or something. And I figure if I write, I might as well submit. And so I was submitting, writing and submitting. And then I wrote “Soulless” as kind of a challenge to myself. I’m a bit of a perfectionist. I have a propensity for rewriting things over and over and over a million times and never actually finishing anything. And so “Soulless” was like, “You will take six months, you will write this weird book.” This was during the paranormal romance and urban fantasy bubble of the late ’90s, early 2000s. And I was like, what I really want from…I want a bunch of things, right? I want women to write funny stuff in genre, commercial genre. And that’s pretty rare. Most of the writers I knew who wrote funny stuff were like Terry Pratchett, Christopher Moore, Jasper Fforde, like a bunch of dudes. And I was like, “Where are my ladies writing funny? Where’s my urban fantasy set in a historical time period?” You know, I wanted all of these things and nobody was writing it. And finally I was like, “Well, that means I have to.” Jeff: Take the challenge. Gail: Take the challenge. And I really did write it as a challenge. And “Soulless” is a mashup. It tends to be what I write, obviously. I mean, I’m here talking about, you know, space, cozy mystery romance. So I obviously like mashing up things. And so “Soulless” is steampunk, urban fantasy, comedy of manners, romance. It’s a bunch of these different things. And I was like, no one will buy this because I had been in and out of the publishing industry and submitting short stories and I was like, “This…it doesn’t have a place in the market. There’s no shelf it sits on, like, no one’s gonna buy this. But I wrote it so I might as well send it out.” And I had one of those slush pile telephone calls from New York where they like…within a month somebody wanted to buy my silly little bit of fluff. And I was like, “No, you’re joking.” And so “Soulless” was a slow burn. It hit the market and it was really word of mouth. The librarians and the independent bookstores were like behind me 110%. They just loved this crazy little book. And I think it was mostly the funny, but you know, super strong heroine and, you know, like gruff, overly emotional werewolves and queer characters from the get go. And it just appealed to, you know, a kind of segment of society. So I was right about to do my defense when “Changeless,” my second book, hit the hit The New York Times and that kind of seed changed everything. It changed marketing, it changed how much money New York was willing to offer me and my partner at the time was like, “I make enough money to support us. Why don’t you see if this…why don’t you take a break from academia and see if this writing thing works?” And I did and I haven’t been back. Jeff: Well done. Ten years on. Gail: Yeah, a lot of it’s serendipity. And a lot of it is good friends. And then a lot of it was also like, I am super…I’m an archaeologist. Archaeologists are like the organizers of anthropology departments. You know, we’re logistics, we get large groups of people into foreign lands and then make them shovel dirt around, you know. We feed them and house them and blah, blah, blah. You know, we’re big on spreadsheets and organizing. So I already had that kind of part of my personality that I think not a lot of authors have. And so when I was successful, I was ready to be like, “Okay, let’s figure out how many books I can write in a year. Let’s figure out, you know, like… I like trad, but maybe this independent publishing thing is interesting. Let me go research that and experiment with that. You know, let’s try this thing.” I’ve always been like that. Even with my traditional publishers, like they would be like, “You sell really good in eBooks.” And I was like, “That’s because I have romance readers.” And they were like, “How do you feel about maybe doing this strange BookBub thing?” And I was like, “I think that’s a great idea. Why don’t we do that?” You know, it’s like I am game. So I think that has also helped is I’ve always been willing to take a risk, partly because I have a safety net. It’s like I can always go back to being an archaeologist. That’s fun too. Jeff: What’s your overall process? I mean, it sounded like, if I understood from our “The 5th Gender” discussion, it almost sounded like you did the first draft of that book at the retreat. Gail: Yeah. I work really well, it turns out, in a competitive environment. I didn’t realize, but if…I really am one of those writers who I’m social in terms of I like to sit across from somebody at a cafe and just type and just the act of having another writer or a bunch of writers around me also typing is really helpful to me. And part of it is kind of looking over and being like, “How many words have you done? Oh shoot.” And then just typing some more, you know. But yeah, so I do this one retreat every year and I know I can do 40,000 words at that retreat, which is either one novella or most of one of the G. L. books. So I usually sort of get prepared ahead of time with that preparation is writing the first 10,000 or just get…I’m an outliner, so I’ll get all the outline ready. I’ll get all the world building ready. And once I hit the ground there, I can just turn out a bunch of words and that’s great. I try to do a couple of other kind of long weekend baby retreats. I’d love to find other week-long retreats. But the style that I like is pretty rare. And the style that I like is just a bunch of writers writing and no workshops or critiques or anything. So I do that and then most of the rest of the time I am not somebody who can handle multiple projects. I learned that about myself the hard way. So I have to be working on one book and then close that book out and then move to another one. And so if it’s an independent project, what I’ll often do, so if it’s something that I’m gonna be self-publishing, I’ll often write the whole thing on a retreat or over the course of a couple of months. And then just put it to bed and then focus on incoming copy edits or a proof pass or writing a completely different project, and let it sleep if I can. I find that that marination really helps. And then I’ll go back and do a reread. And I’m a multiple editor. I think a lot of comic writers have to be because I do passes for like different kinds of comedy. So I’ll do like a word play pass and then I’ll do a sort of a slap stick pass. And then I’ll do like rule of three descriptive passes to try and get as much different kinds of humor back into a book as possible. And so, and then I have an alpha reader or two and they read before it goes either into my New York editor or off to my beta readers. And then I actually hire and use a developmental editor for my independent stuff as well probably because that tends to lean more romantic. And when I first started writing it, I didn’t really think of myself as a romance author. So I wanted to make sure that I was getting kind of the beats right for romance. So I have an editor who specializes actually in gay romance, who reads all of my romances and gives me feedback. And then it goes to beta readers for the Parasol-verse in particular because they’re like, they’re 25 books in that universe and there’s lots of crossover characters. So most of my beta readers are actually just super fans who are obsessed with the universe and have written me like either critical letters about mistakes that I made in terms of like getting character names wrong or eye colors or something. And usually I’ll be like, “You, would you be interested in being a beta reader?” Jeff: Right. Put those people to work. Gail: Exactly. I was like, “If you’re going to do this anyway, how would you like to get everything ahead of time?” And I give them lots of extra perks as well, special editions and stuff. Yeah, so it’s quite a process at this point. But my beta readers are killer. I’ve got just a team of four now and they’re really fast and great. I love them. And then I have a couple of awesome copy editors that I use and then a proof. The Parasol-verse gets a woman named Shelley Adina, who’s a fantastic steampunk author in her own right and a regency and who’s really, really good on the Victorian era. So it gets a world – like historical proofing basically. And then I have a formatter. I’m a big fan of finding people who are really good at what they do and hiring them to do it for me. Like I could change my own oil, I’m sure, but I’d really rather find a good mechanic, you know. And that’s how I feel about the book world as well. So I have a fantastic cover art designer I love working with and I just got to put my team in place and then hope that no one gets sick. Jeff: Right. That’s the key. Nobody can get sick. Not right now. Gail: Nobody get sick. Nobody can leave me. Very floored when that happens. Jeff: So you mentioned that you read a pretty broad swath of stuff. What are you reading right now that you’re loving? Gail: So I just did a reread on Amy Lane’s “A Fool and His Manny,” which because it got nominated for the RITA award and it was one of the few that did that was queer. So I had read it before, I just did a reread on that and I still love it. It’s very cute, and I love Amy. Amy’s one of the nicest human beings in the world. So that was really fun to redo. And I’m a huge fan of Mary Calmes. I don’t know how to say her last name. Jeff: You actually got it right. Gail: Did I? Jeff: You did. Gail: Oh, good. Yes. I will read… Pretty much she’s an auto buy for me. I just find…I know that there are tropes in place that…but I just find her stuff really…she’s a comfort read for me and as somebody who writes what I hope is comforting for others, like I’m always hunting for authors that give me that same sensation. One of my like constant of all things, comfort, reread rotation is Alexis Hall’s “For Real,” which is a fantastic BDSM, but it’s just like, I don’t know what, the writing is so good. And I will reread R. Cooper until the cows come home, the “Being(s) in Love Series,” which I really, really adore. So, which is an urban fantasy basically. Jeff: So you’re a podcaster also on top of all this other stuff. Gail: I am. I know. That is like completely not connected to anything, side project. Jeff: Well, I’m looking at you, I’m reading the website, getting to know kind of what I wanna ask about. I’m like, “A podcast? Wow. Okay.” And it’s about travel hacks called “The 20 Minute Delay.” How did this come about? Gail: So one of the things that happened to me in the course of this career is I went from being an archaeologist, I traveled a lot as an archaeologist, to being an author where it turns out I travel like five times as much. When I was booked, where I’m regularly, I was doing two book tours a year at least. And that was not counting all of the conventions and stuff I was doing. And a book tour is like 10 cities in 10 days. I mean, it’s crazy traveling. So I turned into a frequent traveler and I’m an organizer and I like to hack things and figure out the most efficient way to do everything possible. And I realized I was doing that with travel. And there are two things that I can talk…well, there are three things that I could talk about, books that I love, like literally until the cows come home, food that I love to eat, and travel hacks. And then I met my friend Piper. And Piper has a day job that has her traveling 80% of the time. And she has, if possible, more travel hacks than I do. I was basically like, “Piper, let’s do a podcast. It’ll just be like 20 to 30 minutes and we will just get on and we will chat about a place that we’ve been recently, and some like delicate matter of etiquette when traveling, like whether you recline your seat or not and how you deal with that,” or recently we did a really good one actually on rental cars. I don’t rent a car that often, but Piper does all the time. And she had some awesome tips for like how to get the best rental car and, you know, what apps to use and all that sort of stuff. And then we do a little gadget where we’re just like, we test a gadget, like a new neck pillow or something and then we talk about, you know, what is that little gadget thing. And sometimes it’s just like, I like the snacky bags. Like you should always have at least two plastic snacky bags with you because they just always come in useful. So sometimes it’s a gadget like that, but we have a really, really good time. And I’m a voracious podcast listener. Like when we started, I’m a fan of this show. So I figured, generally speaking, you eventually become a podcaster if you are a big fan of listening to them. Jeff: That’s probably true. And I think for any of our listeners who are, you know, thinking about, you know, their trips to GRL come October, start listening to “The 20 Minute Delay” now to get all your travel situation put together. Gail: Because Piper and I are both authors, like we don’t…we try to couch our tips as much as possible in terms of anybody can use it. But we are both women. We are women who travel alone and we are both authors. So we will tackle things like how to travel with a bunch of books, like how to fly with 50 bucks or what have you. And we also talk about like safety when you’re staying in a hotel by yourself and that sort of thing. Jeff: So what’s coming up for you next this year with the writing? We’ve got “The 5th Gender” out, what’s coming next? Gail: Next, I have the final book in my Custard Protocol series coming out, which is “Reticence.” And that’s book four of the Custard Protocol that comes out at the beginning of August. And that’s actually rounding out the series in the Parasol-verse for a little while, my steampunk universe. I’m not ruling out doing another series in that universe, but I think I’m gonna take a little break. And I’m on proposal for a new Young Adult series. So who knows? It’s traditional, so it could take forever, could suddenly happen. You never know. And then in October I have a special collector’s edition coming out from Subterranean Press called “Fan Service,” which is for my super fans, which has my 2 supernatural society novellas bundled together with an exclusive short story that’s a hardcover fit, super fancy addition that there’s only gonna be 526 of those printed. And so that’s my October release. It’s so pretty. They can be very pretty covers, Subterranean. Jeff: That’s cool. And what’s the best way for folks to keep up with you online so they can keep track of all this? Gail: Well, in addition to everything else, so in case anybody’s in any doubt, I kind of have no life. I just did…this is like what I…like, I listen to podcasts, I read, and I play online, and occasionally I write, you know, because that’s my job. So I am on all the things online. I genuinely like social media. I know. I know, it’s crazy, but you can pretty much find me on any platform that you like. If you google Gail Carriger and then the name of the platform, I will probably pop up. And I try to use the platform in the way that it’s best suited. So, you know, there are pretty pictures on Instagram and there are lots of pinned gorgeous dresses on Pinterest and historical dresses and crazy aliens. And then I also have a newsletter. The newsletter is definitely for super fans. So it’s very chatty and it’s full of like sneak peeks as to what I’m actually writing and not talking about online yet. And I do freebies and giveaways and stuff there. Jeff: We’re going to link to all that good stuff in the show notes, of course, so people can find it easily. Gail, thanks so much for hanging out. It has been so much fun. Gail: Oh, it’s been a real pleasure. I can’t say how delighted I am to be on and I can’t wait to listen to this from the other side.

Jeff talks about the upcoming release of Netminder (Codename: Winger #4) and a blog post he’s written that talks about the impact the series has had on one reader. The guys also talk about the FX series Fosse/Verdon. Jeff reviews With A Kick Collection #2 by Clare London with narration by Joel Leslie and The Whispers by Greg Howard with narration by Kivlighan de Montebello. Will reviews American Fairytale by Adriana Herrera. Jeff & Will interview Adriana about the Dreamers series, including the soon to be released American Fairytale. Adriana also discusses the food that goes into her books, writing diverse characters, how her job as a social worker plays into American Fairytale and what’s coming up next in the Dreamer series. Complete shownotes for episode 188 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: With A Kick Collection #2 by Clare London, narrated by Joel Leslie. Reviewed by Jeff.Back in episode 144 I reviewed the audiobook of the first With A Kick collection. Now with collection two, once again the writing of Clare London combines with the narration of Joel Leslie to make a super awesome experience. We’ve got two stories in this collection–Pluck and Play and Double Scoop. In Pluck and Play delivery person Curtis is saved from a homophobic attack by cowboy/singer Riley. It’s an interesting meet cute since moments after Riley dispatches the attacker, he and Curtis fall into some delightful banter. Once they meet, they continually run into each other. Riley occasionally performs on the sidewalk across the street from the With A Kick ice cream shop, which is where Curtis often makes deliveries and hangs out with his friends who run the shop. The difficulty for Curtis and Riley–and I love how Clare handles this–is that they have to decide if the thing between them is just a one-off bit of fun or something more. Riley’s supposed to go back to the States eventually, plus he’s got issues going on with his family. Meanwhile, Curtis is hesitant to let anyone get close to him again after his last relationship was so disastrous. Clare does a wonderful job of finding the moments of tenderness for Curtis and Riley while also dealing with their troubles. I think I’ve developed a thing recently for the bodyguard trope. Riley has a protector streak that I loved so so much. As soon as he finds out what Curtis’s ex is up to, he wants to put a stop to it. The same can be said to for Curtis because he wants to help Riley deal with his family. It’s so clear these two are meant to be together and once they figure how to get out of their own way–and take care of their pasts–to get their happily ever after to they are golden. With Double Scoop, Clare has written my favorite of the With A Kick stories. This one centers on shop owners Patrick and Lee. As the story opens an explosion rocks the shop, injuring Lee and leaving Patrick in a fit of concern for his friend and their business. These two have had an ongoing business and flirty relationship through the series and now they get their moment in the spotlight. Patrick, as the slightly older one, can’t imagine why the younger Lee would be interested in him. He doesn’t feel particularly accomplished, despite the business, or particularly attractive. Lee, however, knows exactly what he wants and keeps going for it even though Patrick doesn’t make easy for Lee to get and stay close. Clare toys with them and the reader in the most delicious way–bringing them together and then causing a rift. It made for a fun yet tense read going back and forth. Luckily the amazing cast of characters that Claire has developed over the series come together to help get the shop reopen and bring the two men together. Their friends know what’s best for them even if they can’t figure out how to make it work. Both With A Kick collections are great for sexy short romances that have the best happily ever afters. You can’t go wrong picking it up on audio either. Joel Leslie does a tremendous job with a large cast of characters, particularly in Double Scoop since almost everyone who’s appeared in the series shows up here. Joel deserves a special shout out for Riley, who is the only American accent and it’s a southern one too. I enjoyed listening to him go back and forth between Curtis’s British and Riley’s southern. So if you’re looking for some fun reads, that will surely make you want some ice cream this summer, pickup With A Kick Collection #2 by Clare London … and grab the first one too if you haven’t already. The Whispers by Greg Howard. Narrated by Kivlighan de Montebello. Reviewed by Jeff.This was a quite an unexpected middle-grade gem that often surprised me with the depths it explored. I’ll caution as I get into this that the end packs a lot of emotional punch and some readers may want to tread lightly on this young man’s journey because it’s heartbreaking while it does conclude in a very satisfying and fulfilling place. Eleven-year-old Riley is missing his mama. She’s been gone for a few months and Riley doesn’t know why. He’s one of the last to see her and he meets regularly with a police detective to try to fill in pieces of what he knows. However, he gets frustrated with the speed the case is moving. He remembers the story his mama used to tell him about the whispers, little blue fairies who live out in the woods. He can’t help but wonder if the whispers might be the key to getting her back. What I loved so much about this book is how strong Greg made Riley’s narrative, keeping true to how an eleven-year-old might perceive the world. Riley already knows that he’s gay. He refers to that is one of his “conditions” that he has to keep secret, and this is not his only one. He also crushes on Dylan who he refers to as the redneck superhero. Dylan’s in eighth grade and he keeps up his superhero status by actually acknowledging Riley, and occasionally defending him against the school bully. Riley convinces his best friend Gary to go on an adventure in the woods to find The Whispers. Again, this trip reveals so much about Riley as he has to deal with a hobgoblin (or was it), the fact that Dylan may not be a superhero (or maybe he is) and the consequences of saying the wrong thing to your friend all the while trying to do the right thing so The Whispers will help him. One of the extraordinary characters in this book is Tucker the dog. Tucker is Riley’s faithful companion, always at the boy’s side to nudge him in the right direction and keep him safe. The dog has an amazing personality that shines through Riley’s narrative. I don’t think I’ve ever read a dog on a page quite like Tucker and I absolutely loved it. It’s a credit to Greg that he had me so invested in Riley that I didn’t try too hard to piece together what was happening. As the plot hurtled toward its conclusion I was constantly surprised and pivoted between sadness and happiness as the revelations came fast and furious. Kudos to Kivlighan as well for capturing Riley so perfectly. It was a very satisfying audiobook experience. This was my first Greg Howard book and I’ll definitely check out his other titles. I do very much recommend The Whispers if you’re looking for a superb read featuring an eleven-year-old who is going through a lot but comes out stronger and wiser on the other side. American Fairytale by Adriana Herrera. Reviewed by Will.When Camilo, a NYC social worker, goes to an absurdly swanky charity event that his boss can’t attend, he’s intent on enjoying the special evening, which includes chatting up the hottie he meets at the bar. After a few drinks and some suggestively flirty banter, he and Mr. hot stuff find a dark corner and make the night truly memorable. The next morning, Camilo’s boss introduces him to Tom, the millionaire who’ll be financing their agency’s major renovation project. Tom also happens to be Camilo’s hot charity gala hook-up from the night before. Aware how awkward the situation is, Tom agrees to keep things strictly professional from now on, but also asks that Milo be the point man on the project, keeping him up-to-date on the renovations. Their weekly meetings begin to look more and more like dates – a meal at a fancy restaurant, a walk through the botanical gardens. Camilo is no fool, but as he gets to know Tom better – he’s certainly not your average philanthropic millionaire, there is more than meets the eye – the pretense of “keeping things professional” begins to hold less and less appeal. When they can no longer deny the attraction, Tom takes Milo back to his place. The sex is amazing (of course), but the afterglow is short-lived when Tom’s ex drops buy with their daughter. Tom shares custody of Libertad, his daughter, with his former husband. Learning of all of this (which Tom failed to mention up until that point) briefly throws Milo for a loop, but it’s hard to resist the precocious the little girl, and Milo falls even harder for the millionaire and his ready-made family. A situation with Milo’s mom has him taking on more work and financial responsibility and, in addition to that, he’s working overtime as the massive renovation project is wrapping up. He’s stretched almost to the breaking point. When Tom offers to help, the fiercely independent Milo insists he has it all under control. Tom quietly takes care of things. It’s better to ask for forgiveness than permission, right? In this case, no. Camilo is furious. As a reader, it’s hard not to feel frustrated by Milo’s stubborn streak. Your boyfriend is a millionaire for god’s sake! Get over yourself! But it eventually becomes clear that Milo is, of course, right. Tom’s intervention robbed Milo of his own autonomy. It’s Milo’s choice whether or not to ask for help – no one else’s. This is a deal-breaker for Milo and it causes a major rift in their relationship. Tom has to find a way to fix things, by doing the hard work and not using his money to solve their problems. This is a romance, so Tom figures things out, and pulls off a grand gesture that is less grand, and more heartfelt and considerately thoughtful – which is exactly what Milo needed. It all wraps up with swoon-worthy family vacation to the Dominican Republic. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish Hank Edwards and Deanna Wadsworth’s new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Welcome, Adriana to the show. Thanks for being with us. Adriana: Thank you for having me. I’ve been looking forward to this for weeks. Jeff: So have we, to be honest, since we’ve read “American Dreamer” that we loved so much. So, a good first question is, what was the inspiration behind the “Dreamer” series? Adriana: So, basically, I think I wanted to write Afro-Latinx characters. I’ve said this in a couple of other conversations I’ve had about the book. It was really a specific time, a couple of years ago, right after the election when there was just a lot of negative conversation around the place of immigrants in the U.S. And I just really felt compelled to write a story that I felt can honor my identity which is Afro-Latinx, and the Afro-Latinx immigrant experience. And I think representation has also been an issue for me, with romance specifically. There are stories of people of color in gay romance, but I felt like they were either really surface characters or there was like a real, like, toil story. You know, the person had to go through every kind of horrific thing. So, I wanted to write something that could be nuanced and also show the joyfulness and the beauty of being a person that’s Afro-Latinx and all the amazing things that we come with. So, that was kind of where I was coming from. And I also really, really wanted a book literally full of…just like the gayest, most black and brown book I could write. Jeff: That should almost be a quote on the cover. Will: That’s funny. Adriana: Yeah. I wanted it to be super gay, super black, super brown. Jeff: So, right before we did this interview, Will raved about “Fairytale.” Tell us, in your own words, what that story is about, and kind of how it falls in the series. Adriana: So, it’s the second book in the “Dreamer” series and it’s set in New York City, which is different from “Dreamer” which is set in Ithaca. And it’s about Camilo Briggs who’s one of the best friends of Nesto from the first book. And he’s a Cuban-Jamaican social worker. And he works in the domestic violence field, which is the same field that I work in. And he meets this, like, very hot stranger at a gala and he turns out to be a big donor for the agency that he works for, that Camilo works for. And Tom is an interesting character because he’s a billionaire, which we love in our romances, but he’s also Dominican and white-passing, which is something that I really wanted to explore in a book. What it means to be Latinx but also kind of have the privilege of presenting as a white person, and what that means, and how hard that is to navigate. So, I guess, it’s about… It’s a fairytale, it’s a modern-day fairytale but it’s also, again, like a different side to the Latinx experience. And it’s sweet and fun, and cute and sexy. Will: Yeah, it definitely is. First, before we get to the next question, I want to commend you on the sort of…what I found really enjoyable about not only “American Dreamer” but “American Fairytale” as well is the group of friends, the sense of found family that comes across really strong in this series. I think it’s exceptionally well done. And especially in that first book because, like, right at the beginning, from the get-go, you introduce this, frankly, a really large cast of characters. And I think, with a lesser author, that could frankly get confusing. I know when I read a book, I get confused easily if there are five, six, seven people, you know, names and personalities all thrown at you at once. But each of your characters, each of the friends in that group are so clearly delineated and…especially in that first book, in the opening scene, you give us the briefest glimpses of who they are, and we understand right away where they kind of fit in the group of friends. And of course, they’re all wonderful, and interesting, and funny. They give each other shit like good friends do. I love this group of guys so much. Adriana: Thank you. I have to admit, they’re not my friends, but those four guys are very inspired on my, like, really core group of friends in my early 20s in the DR…when I was still in Dominican Republic. My core group of friends were mostly gay men because my cousin, who’s like my brother, who’s 14 months older than I, is gay. We kind of just like started hanging out with this group of, like, queer kids in the DR. Which in the ’90s was kind of an interesting crowd to be in just because it wasn’t really okay to be openly gay. And we had so much fun. And we did so much, like, crazy stuff together. And I just kind of really wanted to kind of like write a love letter to those friendships and those years. And a lot of them ended up coming to the States at the same time I did, in my early 20s. So, I think they feel so real because they are, like, real. Jeff: These books are getting so much praise. What do you think is resonating with the readers? Adriana: I think people are more open now, or I think there were always those that were open to reading about those different experiences. But I think there’s a particular appetite now for reading more characters that are bringing with them a different lived experience. And I think that might be part of it, like why people are interested in the story. And I think everybody can connect to a striving story, you know. I think Nesto, and Jude, and Camilo, Patrice, Juan Pablo, all of them, they’re just striving to be who they know they deserve to be – for the lives that they’re working for. And I think everyone can relate to that and that struggle of fighting for what you want. Jeff: Did you also intend to make everybody hungry with “American Dreamer?” Adriana: Yes. Yes. Jeff: Was that part of, like, your side plot? Adriana: Yes. Yes, I did. I wanted because…also that’s the other piece, like Caribbean food is very similar but very different in many ways. And I talk about that a lot in “Dreamer.” And it’s the…I wanted to just show people, like, all the different flavors and how we’re all connected. So, I think it’s something that doesn’t really get talked about as much, the wide variety of our flavors. So, I did intentionally want people to be very interested in Caribbean food. I wanted people to Google Dominican restaurants and it sounds like I succeeded. Jeff: I think you did, yeah. I haven’t gotten into “Fairytale” yet. Is there food there also or do we break away from the food a little bit? Will: A little bit. Jeff: A little bit. Adriana: Yeah, a little bit. It’s not as much food. It’s more of…I feel like “Fairytale” is more about, like, Harlem and The Bronx. I have a lot of places in Harlem and The Bronx because again, there are a lot of romances set in New York City. Not many of them are set in Harlem and The Bronx. So, I wanted to go to the places where…like, the diaspora that I belong to, came to. So, I think that’s more… I’m hoping people Google places to go in The Bronx and Harlem with this one. Will: That is a good goal to have, most definitely. Now, with this group of characters, they come from a lot of different backgrounds, what is your process for basically ensuring accurate representation? Is it all from your own personal experience or something else? Adriana: Yeah. So far in this series…and I’m sure that as I write more, then I’m gonna have to go outside of that, but so far in this series, I’ve really gone with origin stories that I know of or from people that are, like, my friends or things like that, like Camilo’s mom, for example, is a Marielita, which was a specific group of Cuban refugees that came at a specific time to the U.S.. And I kind of touched upon that because that’s a very important influx of immigrants that came at a specific time. And they’re all particular experiences that I have been connected to through my friends or family. But I do think writing diaspora is something that people need to be more thoughtful about. So, I try to think a lot about like when did this person come, how did they come, what was the political situation in the U.S. at that time, how they would’ve been received. Like, with Patrice, you know, he’s Haitian and he’s black. His experience and the way he was received would be different than, for example, Camilo’s mom who came as a Cuban refugee and had protected status as she came in to the U.S. So, it’s very…like, there’s nuances there in the context that really needs to be thought about because it really impacts how the person can integrate into American life. Will: And speaking of writing from experience, you have a job in social work and advocacy, did you use your own personal experience when writing about Camilo’s work? Adriana: Yes. So, Camilo’s work and my work…I mean, I really drew from what I do every day to kind of build Camilo’s agency. I mean, kind of like my wish list almost. I wish we could have a guy that just wants to drop $2 million on my agency and tell us, “Do whatever you want with it.” So, I think it was like my fantasy of what it would be like to be in an agency that is just being well-funded, and, like, resources are just there to do the work. So, I think it’s like my own fairytale of what it would be like to work, and just have a millionaire just drop money on us. But, yes, it’s very, very connected to my own work and kind of like my philosophy around the domestic violence field and how the work should go. Jeff: I like how you set the books in our extremely modern times too. And I think in “American Dreamer” as Nesto faces the discrimination of the, who I like to call the evil woman, how he deals with it because I think that it tells a story that not everybody necessarily thinks about all the time. Adriana: Yeah. And I really wanted to contrast, even in the book like Jude’s own reactions to the racism and the obvious discrimination and sabotaging and Nesto’s reactions to it, and the reality that there are different consequences for some people than to others. And that that’s a reality you kind of just have to work with. Jeff: And I loved how he dealt with it too, taking that high road. I just like, “Go, Nesto.” Adriana: Right. I mean, it’s a reality, like, it could have a consequence that was like very, very difficult for him. So, he couldn’t just like get into a thing with this lady. Jeff: Right. “American Dreamer” was your first book. How did you come into writing romance and specifically MM romance? Adriana: So, I’ve been toying with the idea of writing an MM romance for a long time. I’ve been a MM romance reader for, like, a long time. I was at the first GRL (Gay Rom Lit Retreat). I’m like an OG of MM romance. But I was a lot more involved in the community, and then kind of stepped back. I got busy and I just kind of kept reading, but I had it in the back of my mind. I find that what MM romance brought to my life, in terms of dynamics and relationships, and seeing…like I said, having friends all my life that were gay men, and me being so close to so many men who were like looking to fall in love and not being able to see love stories. I remember when I started reading LGBT books, they were very, like, sad, very sad stories like in the ’90s, right? I mean, I grew up in the ’90s. And so just finding your romance was something that was so incredibly wonderful for me. And I thought, “Wouldn’t it be even more wonderful if I could actually find my particular experience and the particular experience of the people who I love in those books?” So, it was kind of like a combination of going to a place…like the type of story that had been really meaningful to me, and then kind of putting my own experience into the space. Jeff: What was it like to write the first book after having read so many? Was it kind of an easy process or was it crazy and hard and took years or…? Adriana: So, it didn’t take me that long, if I’m honest, but I had been thinking about it for a long time. So, before I actually started writing, I kind of did a whole year of reading a lot of craft books, and going to workshops, and trying things. And I actually started a book set in Ethiopia, which is also a gay romance. And I got through a third of that and I was like, “I cannot write this book. I am not equipped to write a gay romance in Ethiopia right now.” And I decided I wanna do this story, this “Dreamer” story. And then that’s when I started it. But it was like a year and a half before I actually felt brave enough to actually write it. Yes. Jeff: I’m so glad that you found that bravery. Who would you say your author influences are? You say you’ve read, you know, MM forever even before it was truly MM, back in the sadder days? Adriana: Yeah. I have a lot of authors that…I mean, I’ve loved a lot of authors from the beginning that I think, I don’t know if I emulate, but I think about a lot in their…kind of how they render a story. Like K.J. Charles, I think, is a wonderful author. I think she just does things that are like phenomenal in writing. E. Lynn Harris was probably the first queer romance that I ever read. I think it’s really sad that he’s not, like, in the canon of what we talk about when we talk about queer romance. So, yeah, but I mean there’s a lot of writers I like. Amy Lane’s early work was super significant for me. I thought her…some of her early books are really some of my all-time favorites. So, yeah, there’s a lot of authors that I kind of go back to and read just to kind of be inspired by the way that they render a story. Does that make sense? Jeff: But what is it about those books that resonated for you so much? Adriana: I think…well, first of all, it was they felt familiar in a way that was like a discovery almost, because I didn’t really ever know any people…a black man who was really exploring the falling in love and the feelings, and the struggle, and the conflicts of trying to make yourself happy, and to find the love that you have…to keep the love that you’ve discovered, right? So, I think his (E. Lynn Harris’) books thought were just so beautifully written, and so tender, and so heartbreaking. It was just wonderful. I think being raised in Dominican Republic where there’s, toxic masculinity on steroids, like, the tenderness of his books really was something that I hadn’t read before. I think it just was kind of like eye-opening to me. Will: Now, so far in your “Dreamer” series, we’ve had Nesto and Jude’s story, and Camilo and Tom’s story. There is, of course…thank God, there’s going to be a third book. Whose story are we gonna get in that one and what can you tell us about that one? Adriana: So, it’s Patrice’s book. Patrice is Nesto’s friend who is a Haitian-American man, who’s a professor. It’s set in Ithaca. He conveniently gets a job at Cornell in the economics department and moves to Ithaca. And he reconnects with Easton Archer who is a character that we meet in “Dreamer” who’s a prosecutor, an assistant district attorney in Ithaca. And Easton is white, so it’s an interracial romance. Yeah. Jeff: When does that one come out? Adriana: That one comes out in October. I just saw a proof for the cover last week…or no, earlier this week, and it is so nice. I love it. I think it’s my favorite one, and I really love the covers for both books so far. I’m calling it my Black Lives Matter romance, although it’s not super intense, but it’s definitely…like the conflict between Patrice and Easton is definitely revolving around kind of having to navigate both of, like, their positions in life. Will: We got a brief glimpse of Patrice and Easton, like you mentioned in that first book. And then in “American Fairytale,” there was a scene with all of the friends together and Patrice sort of like phones in on Skype while they’re, like, dishing about Camilo’s love life, which was very, very funny. So, I’m genuinely looking forward to Patrice’s story. I think it’s gonna be amazing. I can’t wait. Adriana: I know. I’ve been revising it, like I said, and I think it’s a sweet story. And then, there’s a little bit more of two characters that people have been curious about. Ari and Jin, who are employees of Nesto, and they are in their little tiny young person romance. So, they’re like a little cute element for a love story. It’s called “American Love Story.” It’s the title of Patrice’s story. Jeff: Cool. And then you mentioned before we started actually recording the interview that you’re writing the fourth book right now. Any teasers on that? Adriana: So, that one is not an MM. It’s an MF, actually. It’s Juan Pablo’s story. And Juan Pablo is…it’s like a, I’d say, a second chances story. And the heroine is Priscilla who is Nesto’s cousin, who’s a police officer. And it’s called “American Sweethearts.” So, the book starts with a wedding in the Dominican Republic, but I’m not gonna say whose. Jeff: Oh, such a tease. Will: Oh, man. Adriana: Yeah. I’ll tease a little more when I have…I feel like I can’t tease too much on this book because it’s not even halfway done yet. But right now, I’m writing the first few chapters and they’re all in this wedding in the DR. So, everybody is there. Jeff: But I do like how you…we’ve seen with some traditionally MF series where an MM book ends up in the series. And I like how you’re kind of spinning that around too, you’ve got an MM series so far and you’re putting an MF book in it just to, like, broaden that universe out. Adriana: Yeah. So, my kind of little tagline is like, I write romance full of people who look and sound like my people. And there’s a lot of my people who are gay men, like so many of them. But not all of them are. So, I wanted to, in this series at least, have one story where, you know…like both Priscilla and Juan Pablo are queer. Like, she’s pan, he’s bi. But it’s also like a different type of, you know, experience because they’re both engaging in a straight relationship, which brings in…has its own privileges in terms of how it appears. So, I also wanted to explore that a little bit. Jeff: And I think exploring the pansexuality too will be interesting because that doesn’t turn up in a lot of books, at least the ones that cross my radar. And I think it’s nice to see that representation alongside the ethic background representation that you’re bringing as well. Adriana: Yeah, yeah. And it’s something that I think it’s…because of their age, I’m trying to kind of like engage a little bit in even Priscilla arriving to a place where she’s like, “Oh, actually, I’m pan,” as opposed to like, “I thought I was bisexual,” and how she arrived at that. Because I think that’s something that, for people my age, like I’m 40, it’s something that we arrived because we didn’t even have the language for that. Like, 15, 10 years ago, we were like, “Oh, I think I’m gay.” But then it’s like, “Oh, but there’s a whole spectrum of sexuality, gender identity.” And I think there’s so much that we didn’t know – that we know now – that should be coming up in books. Jeff: It’s great that you’re leading the way to kind of get some of that out there, too. Adriana: Yeah. It’s a great time to be writing romance, I think. Jeff: So, besides the “Dreamer” books, is there anything else coming up that you’re looking to write in the coming…I’ll say years since “Dreamer” has you going for the rest of this year probably, if nothing else. Adriana: Yeah, yeah. So, I do have a couple of things that I’m working on. I’m in the process right now of getting out this…I did write the gay romance set in Ethiopia, and I’m in the process of…like, I should have some good news about it soon. And it’s a romance set in Ethiopia, and it’s a Dominican-American relief worker. I did international relief work for a long time. And I lived in Ethiopia for about five years. And so, I really wanted to write a book set in Ethiopia because I have a lot of love for Ethiopia, and my years there were very significant in my life. So, it’s a gay romance. It’s not legal to be in a same-sex relationship in Ethiopia so there are complications. And it’s a Dominican-American relief worker and a colleague who’s Ethiopian, and they fall in love. Jeff: I am so glad you finished that book. You kind of left that off back there when we were talking about it before, because that will be great to see… I have, you know, no experience in any of those spaces. So, to read a romance set there will be an adventure. Adriana: Yeah. It was wonderful to write. Like I said, I have a lot of love for that country. And I think people’s perception of it is like, you know, people starving. And there’s just so much richness and so much beauty and magic in Ethiopia, that I really wanted to just show a different face to it. And I think it’s like a really sweet romance, too. And the setting is interesting. It’s more like a new adult. They’re in their 20s. Jeff: Do you think it will be out this year, maybe? Adriana: I don’t know of this year, but definitely early next year. Like, for sure early next year, yeah. Will: Very cool. Fantastic. Definitely looking forward to that. Now, you’ve given us a lot of amazing information about all of your amazing books, but if our listeners want to learn even more, where can they find out more about you and your books online? Adriana: So, they can go to my website, it’s adrianaherreraromance.com. I’m pretty active on Twitter, and my handle is @ladrianaherrera. And Facebook, I’m also there, Adriana Herrera. So, those are the places…and I’m on Instagram but not as much. Jeff: Very cool. We will link to all of that, plus all the books in our show notes so that folks can easily click on that stuff to find you. Adriana, thank you so, so much for being with us. It’s been awesome talking to you. Adriana: Thank you. It was so much fun and just as amazing as I thought it was gonna be to chat with you guys.

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

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

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

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

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

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

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic that is ripe for review this time of year. We’re talking Influenza… Diagnosis and Management. Nachi: Very appropriate as the cold is settling in here in NYC and we’re already starting to see more cases of influenza. Remember that as you listen through the episode, the means we’re about to cover one of the CME questions for those of you listening at home with the print issue handy. Jeff: This month’s issue was authored by Dr. Al Giwa of the Icahn School of Medicine at Mount Sinai, Dr. Chinwe Ogedegbe of the Seton Hall School of Medicine, and Dr. Charles Murphy of Metrowest Medical Center. Nachi: And this issue was peer reviewed by Dr. Michael Abraham of the University of Maryland School of Medicine and by Dr. Dan Egan, Vice Chair of Education of the Department of Emergency Medicine at Columbia University. Jeff: The information contained in this article comes from articles found on pubmed, the cochrane database, center for disease control, and the world health organization. I’d say that’s a pretty reputable group of sources. Additionally, guidelines were reviewed from the american college of emergency physicians, infectious disease society of america, and the american academy of pediatrics. Nachi: Some brief history here to get us started -- did you know that in 1918/1919, during the influenza pandemic, about one third of the world’s population was infected with influenza? Jeff: That’s wild. How do they even know that? Nachi: Not sure, but also worth noting -- an estimated 50 million people died during that pandemic. Jeff: Clearly a deadly disease. Sadly, that wasn’t the last major outbreak… fifty years later the 1968 hong kong influenza pandemic, H3N2, took between 1 and 4 million lives. Nachi: And just last year we saw the 2017-2018 influenza epidemic with record-breaking ED visits. This was the deadliest season since 1976 with at least 80,000 deaths. Jeff: The reason for this is multifactorial. The combination of particularly mutagenic strains causing low vaccine effectiveness, along with decreased production of IV fluids and antiviral medication because of the hurricane, all played a role in last winter’s disastrous epidemic. Nachi: Overall we’re looking at a rise in influenza related deaths with over 30,000 deaths annually in the US attributed to influenza in recent years. The ED plays a key role in outbreaks, since containment relies on early and rapid identification and treatment. Jeff: In addition to the mortality you just cited, influenza also causes a tremendous strain on society. The CDC estimates that epidemics cost 10 billion dollars per year. They also estimate that an epidemic is responsible for 3 million hospitalized days and 31 million outpatient visits each year. Nachi: It is thought that up to 20% of the US population has been infected with influenza in the winter months, disproportionately hitting the young and elderly. Deaths from influenza have been increasing over the last 20 years, likely in part due to a growing elderly population. Jeff: And naturally, the deaths that we see from influenza also disproportionately affect the elderly, with up to 90% occurring in those 65 or older. Nachi: Though most of our listeners probably know the difference between an influenza epidemic and pandemic, let’s review it anyway. When the number of cases of influenza is higher than what would be expected in a region, an epidemic is declared. When the occurrence of disease is on a worldwide spectrum, the term pandemic is used. Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions. It is most active in the winter months, but can be seen year-round. Nachi: The influenza virus is a spherical RNA-based virus of the orthomyxoviridae family. The RNA core is associated with a nucleoprotein antigen. Variations of this antigen have led to the the 3 primary subgroups -- influenza A, B, and C, with influenza A being the most common. Jeff: Influenza B is less frequent, but is more frequently associated with epidemics. And Influenza C is the form least likely to infect humans -- it is also milder than both influenza A or B. Nachi: But back to Influenza A - it can be further classified based on its transmembrane or surface proteins, hemagglutinin and neuraminidase - or H and N for short. There are actually 16 different H subtypes and 9 different N subtypes, but only H1, H2, H3, and N1 and N2 have caused epidemic disease. Jeff: Two terms worth learning here are antigen drift and anitgen shift. Antigen drift refers to small point mutations to the viral genes that code for H and N. Antigen shift is a much more radical change, with reassortment of viral genes. When cells are infected by 2 or more strains, a new strain can emerge after genetic reassortment. Nachi: With antigen shift, some immunity may be maintained within a population infected by a similar subtype previously. With antigen drift, there is loss of immunity from prior infection. Jeff: The appearance of new strains of influenza typically involves an animal host, like pigs, horses, or birds. This is why you might be hear a strain called “swine flu”, “equine flu”, or “avian flu”. Close proximity with these animals facilitates co-infection and genetic reassortment. Nachi: I think that’s enough basic biology for now, let’s move on to pathophysiology. When inhaled, the influenza virus initially infects the epithelium of the upper respiratory tract and alveolar cells of the lower respiratory tract. Viral replication occurs within 4 to 6 hours. Incubation is 18 to 72 hours. Viral shedding is usually complete roughly 7 days after infection, but can be longer in children and immunocompromised patients. Jeff: As part of the infectious process and response, there can be significant changes to the respiratory tract with inflammation and epithelial cell necrosis. This can lead to viral pneumonia, and occasionally secondary bacterial pneumonia. Nachi: The secondary bacterial pathogens that are most common include Staph aureus, Strep pneumoniae, and H influenzae. Jeff: Despite anything you may read on the internet, vaccines work and luckily influenza happens to be a pathogen which we can vaccinate against. As such, there are 3 methods approved by the FDA for producing influenza vaccines -- egg-based, cell-based, or recombinant influenza vaccine. Once the season’s most likely strains have been determined, the virus is introduced into the medium and allowed to replicate. The antigen is then purified and used to make an injection or nasal spray. Nachi: It isn’t easy to create vaccines for all strains. H3N2, for example, is particularly virulent, volatile, and mutagenic, which leads to poor prophylaxis against this particular subgroup. Jeff: In fact, a meta-analysis on vaccine effectiveness from 2004-2015 found that the pooled effectiveness against influenza B was 54%, against the H1N1 pandemic in 2009 was 61%, and against the H3N2 virus was 33%. Not surprisingly, H3N2 dominant seasons are currently associated with the highest rates of influenza cases, hospitalizations, and death. Nachi: Those are overall some low percentages. So should we still be getting vaccinated? The answer is certainly a resounding YES.. Despite poor protection from certain strains, vaccine effectiveness is still around 50% and prevents severe morbidity and mortality in those patients. Jeff: That’s right. The 2017-2018 vaccine was only 40% effective, but this still translates to 40% less severe cases and a subsequent decrease in hospitalizations and death. Nachi: But before we get into actual hospitalization, treatment, and preventing death, let’s talk about the differential. We’re not just focusing on influenza here, but any influenza like illness, since they can be hard to distinguish. The CDC defines “influenza-like illness” as a temperature > 100 F, plus cough or sore throat, in the absence of a known cause other than influenza. Jeff: Therefore, influenza should really be considered on the differential of any patient who presents to the ED with a fever and URI symptoms. The differential when considering influenza might also include mycoplasma pneumoniae, strep pneumoniae, adenovirus, RSV, rhinovirus, parainfluenza virus, legionella, and community acquired MRSA. Nachi: With the differential in mind, let’s move on to prehospital care. For the prehospital setting, there isn’t much surprising here. Stabilize and manage the respiratory status with all of your standard tools - oxygen for those with mild hypoxia and advanced airway maneuvers for those with respiratory distess. Jeff: Of note, EMS providers should use face masks themselves and place them on patients as well. As community paramedicine and mobile integrated health becomes more common, this is one potential area where EMS can potentially keep patients at home or help them seek treatment in alternate destinations to avoid subjecting crowded ED’s to the highly contagious influenza virus. Nachi: It’s also worth noting, that most communities have strategic plans in the event of a major influenza outbreak. Local, state, and federal protocols have been designed for effective care delivery. Jeff: Alright, so now that the EMS crew, wearing proper PPE of course, has delivered the patient, who is also wearing a mask, to the ED, we can begin our ED H&P. Don’t forget that patients present with a range of symptoms that vary by age. A typical history is 2-5 days of fever, nasal congestion, sore throat, and myalgias. You might see tachycardia, cough, dyspnea, and chills too. Nachi: Van Wormer et al conducted a prospective analysis of subjective symptoms to determine correlation with lab confirmed influenza. They found the most common symptoms were cough in 92%, fatigue in 91%, and nasal congestion in 84%, whereas sneezing was actually a negative predictor for influenza. Jeff: Sneezing, really? Can’t wait to get the Press-Gany results from the sneezing patient I discharge without testing for influenza based on their aggressive sneezes! Nachi: Aggressive sneezes…? I can’t wait to see your scale for that. Jeff: Hopefully I’ll have it in next month’s annals. In all seriousness, I’m not doing away with flu swabs just yet. In another retrospective study, Monto et al found that the best multivariate predictors were cough and fever with a positive predictive value of 79%. Nachi: Yet another study in children found that the predominant symptoms were fever in 95%, cough in 77%, and rhinitis in 78%. This study also suggested that the range of fever was higher in children and that GI symptoms like vomiting and diarrhea were more common in children than adults. Jeff: Aside from symptomatology, there are quite a few diagnostic tests to consider including viral culture, immunofluoresence, rt-pcr, and rapid antigen testing. The reliability of testing varies greatly depending on the type of test, quality of the sample, and the lab. During a true epidemic, formal testing might not be indicated as the decision to treat is based on treatment criteria like age, comorbidities, and severity of illness. Nachi: We’ll get to treatment in a few minutes, but diving a bit deeper into testing - there are 3 major categories of tests. The first detects influenza A only. The second detects either A or B, but cannot distinguish between them; and the third detects both influenza A and B and is subtype specific. The majority of rapid testing kits will distinguish between influenza A and B, but not all can distinguish between them. Fluorescent antibody testing by DFA is relatively rapid and yields results within 2 to 4 hours. Jeff: Viral culture and RT-PCR remain the gold standard, but both require more time and money, as well as a specialized lab. As a result, rapid testing modalities are recommended. Multiple studies have shown significant benefit to the usefulness of positive results on rapid testing. It’s safe to say that at a minimum, rapid testing helps decrease delays in treatment and management. Nachi: Looking a bit further into the testing characteristics, don’t forget that the positive predictive value of testing is affected by the prevalence of influenza. In periods of low influenza activity (as in the summer), a rapid test will have low PPV and high NPV. The test is more likely to yield false positive results -- up to 50% according to one study when prevalence is below 5%. Jeff: And conversely, in periods of high influenza activity, a rapid test will have higher PPV and lower NPV, and it is more likely to produce a false negative result. Nachi: In one prospective study of patients who presented with influenza-like illness during peak season, rapid testing was found to be no better than clinical judgement. During these times, it’s probably better to reserve testing for extremely ill patients in whom diagnostic closure is particularly important. And since the quality of the specimen remains important, empiric treatment of critically ill patients should still be considered. Jeff: Which is a perfect segway into our next topic - treatment, which is certainly the most interesting section of this article. To start off -- for mild to moderate disease and no underlying high risk conditions, supportive therapy is usually sufficient. Nachi: Antiviral therapy is reserved for those with a predicted severe disease course or with high risk conditions like long-standing pulmonary disease, pregnancy, immunocompromise, or even just being elderly. Jeff: Note to self, avoid being elderly. Nachi: Good luck with that. Anyway, early treatment with antivirals has been shown to reduce influenza-related complications in both children and adults. Jeff: Once you’ve decided to treat the patient, there are two primary classes of antivirals -- adamantane derivatives and neuraminidase inhibitors. Oh and then there is a new single dose oral antiviral that was just approved by the FDA… baloxavir marboxil (or xofluza), which is in a class of its own -- a polymerase endonuclease inhibitor. Nachi: The oldest class, the adamantane derivatives, includes amantadine and rimantadine. Then the newer class of neuraminidase inhibitors includes oseltamavir (which is taken by mouth), zanamavir (which is inhaled), and peramivir (which is administered by IV). Jeff: Oseltamavir is currently approved for patients of all ages. A 2015 meta analysis showed that the intention-to-treat infected population had a shorter time to alleviation of all symptoms from 123 hours to 98 hours. That’s over a day less of symptoms, not bad! There were also fewer lower respiratory tract complications requiring antibiotics and fewer admissions for any cause. Really, not bad! Nachi: Zanamavir is approved for patients 7 and older -- or for children 5 or older for disease prevention. Zanamavir has been associated with possible bronchospasm and is contraindicated in patients with reactive airway disease. Jeff: Peramivir, the newest drug in this class, is given as a single IV dose for patients with uncomplicated influenza who have been sick for 2 days or less. Peramavir is approved for patients 2 or older. This is a particularly great choice for a vomiting patient. Nachi: And as you mentioned before, just last month, the FDA approved baloxavir, a single dose antiviral. It’s effective for influenza type A or B. Note that safety and efficacy have not been established for patients less than 12 years old, weighing less than 40 kg, or pregnant or lactating patients. Jeff: Unfortunately, there has been some pretty notable antiviral resistance in the recent past, moreso with the adamantane class, but recently also with the neuraminidase inhibitors. In 2007-2008, an oseltamivir-resistant H1N1 strain emerged globally. Luckily, cross-resistance between baloxavir and the adamantanes or neuraminidase inhibitors isn’t expected, as they target different viral proteins, so this may be an answer this year, and in the future. Nachi: Let’s talk chemoprophylaxis for influenza.. Chemoprophylaxis with oseltamavir or zanamavir can be considered for patients who are at high risk for complications and were exposed to influenza in the first 2 weeks following vaccination, patients who are at high risk for complications and cannot receive the vaccination, and those who are immunocompromised. Jeff: Chemoprophylaxis is also recommended for pregnant women. For postexposure prophylaxis for pregnant women, the current recommendation is to administer oseltamivir. Nachi: We should also discuss the efficacy of treatment with antivirals. This has been a hotly debated topic, especially with regards to cost versus benefit… In a meta-analysis, using time to alleviation of symptoms as the primary endpoint, oseltamavir resulted in an efficacy of 73% (with a wide 95% CI from 33% to 89%). And this was with dose of 150mg/day in a symptomatic influenza patient. Jeff: Similarly zanamavir given at 10mg/day was 62% effective, but again with a wide 95% CI from 15% to 83%. And, of note, other studies have looked into peramivir, but have found no significant benefits other than the route of delivery. Nachi: In another 2014 study by Muthuri et al., neuraminidase inhibitors were associated with a reduction in mortality -- adjusted OR = 0.81 (with a 95% CI 0.70 to 0.93). Also when comparing late treatment with early treatment (that is, within 2 days of symptom onset), there was a reduction in mortality risk with adjusted OR 0.48 (95%CI 0.41-0.56). These associations with reduction in mortality risk were less pronounced and less significant in children. Jeff: Mortality benefit, not bad! They further found an increase in mortality hazard ratio with each day’s delay in initiation of treatment up to 5 days, when compared to treatment initiated within 2 days. Nachi: But back to the children for a second -- another review of neuraminidase inhibitors in children < 12 years old found duration of clinical symptoms was reduced by 36 hours among previously healthy children taking oseltamivir and 30 hours by children taking zanamivir. Jeff: I think that’s worth summarizing - According to this month’s author’s review of the best current evidence, use of neuraminidase inhibitors is recommended, especially if started within 2 days, for elderly patients and those with comorbidities. Nachi: Seems like there is decent data to support that conclusion. But let’s not forget that these medications all have side effects. Jeff: These drugs actually tend to be well tolerated.The most frequently noted side effect of oseltamavir is nausea and vomiting, while zanamavir is associated with diarrhea. Nachi: Amazing. Let’s talk disposition for your influenza patient. Jeff: Disposition will depend on many clinical factors, like age, respiratory status, oxygen saturation, comorbid conditions, and reliability of follow up care. Admission might be needed not only to manage the viral infection, but also expected complications. Nachi: If you’re discharging a patient, be sure to engage in shared decision making regarding risks and benefits of available treatments. Ensure outpatient follow up and discuss return to er precautions. Jeff: Also, the CDC recommends that these patients stay home for at least 24 hours after their fever has broken. Nachi: With that -- Let’s summarize the key points and clinical pearls from this month’s issue J: Even though influenza vaccine effectiveness is typically only 50%, this still translates to a decrease in influenza-related morbidity and mortality. 2. The CDC defines influenza-like illness as a temperature > 100 F with either cough or sore throat, in the absence of a known cause other than influenza. 3. When influenza is suspected in the prehospital setting, patients and providers should wear face masks to avoid spreading the virus. 4. In the emergency department, standard isolation and droplet precautions should be maintained for suspected or confirmed infections. 5. The most common symptoms of influenza in adults are cough, fatigue, nasal congestion, and fever. Sneezing is a negative predictor in adults. 6. In children, the most common presenting symptoms are fever, cough, and rhinitis. Vomiting and diarrhea is also more common in children than adults. 7. Rapid testing and identification results in decreased delays in treatment and management decisions. 8. During peak flu season, clinical judgement may be as good as rapid testing, making rapid testing less necessary. J: Rapid testing may be more beneficial in times of lower disease prevalence. 10. Empiric treatment of critically ill patients should be considered even if rapid testing is negative. J: For mild to moderate disease and no underlying high-risk conditions, supportive therapy is usually sufficient. 12.For more ill patients or those at substantial risk for complications, consider antiviral treatment. 13.Oseltamivir is approved for patients of all ages, and reduces the length of symptoms by one day. 14.When treating influenza, peramivir is an ideal agent for the vomiting patient. 15.Baloxavir is a new single-dose antiviral agent approved by the FDA in October 2018. It works in a novel way and is effective for treatment of influenza A and B. 16.Chemoprophylaxis with oseltamivir or zanamivir should be considered in patients who are immunocompromised or patients who are at elevated risk for complications and cannot receive the vaccination. 17.Consider oseltamivir as post exposure prophylaxis in pregnant women. 18.Neuraminidase inhibitors are associated with decreased duration of symptoms and complications, especially if started within 2 days of symptom onset. J: So that wraps up episode 23 - Influenza: Diagnosis and Management in the Emergency Department. N: Additional materials are available on our website for Emergency Medicine Practice subscribers. For our subscribers: be sure to go online to get your CME credit for this issue, which includes 3 pharmacology CME credits. J: Also, for our NP and PA listeners, we have a special offer this month: You can get a full year of access to Emergency Medicine Practice for just $199--including lots of pharmacology, stroke, and trauma CME--and so much more! To get this special deal, go to www.ebmedicine.net/APP. Again, that’s www.ebmedicine.net/APP. N: If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. J: And the address for this month’s credit is ebmedicine.net/E1218. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!    

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine's Emergency Medicine Practice. I'm Jeff Nusbaum, and I'm back with my co-host, Nachi Gupta. This month, we're back with our old routine – no special guests. Nachi: Don't sound so sad about it! Jeremy was great last month, and he's definitely paved the way for more special guests in upcoming episodes. Jeff: You're right. But this month's episode is special in its own way - we'll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let's start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month's print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O'Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month's team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it's necessary. There are a couple of terms we need to define to help us understand the pathologies we'll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it's measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm's Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury.

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

Take Full Advantage of Transition Services: Enhancing Opportunities for Success - Meet Kylee Jungbauer (Transcript Provided) Kylee Jungbauer is a rehabilitation counselor at state services for the blind. Her concentration is transition age students. We talked to Kylie about what services they provide for students.  Transitioning from high school to college and to the workplace. State services for the blind has a Transition Unit that facilitates a path for students, providing guidance and opportunities for success. From assessments to training, the transition Team offers as much or as little help as needed while promoting self advocacy and independence along the way. Kylee talks about the importance of Summer Programs and how the Transition Team provides opportunities with employment, career exploration and access to training on the tools that will help bring about a successful transition.   Full Transcript Below   Check out below for a list of Summer opportunities and programs.   Check out your State Services by searching the Services Directory on the AFB.org web site.   State Services for the Blind of Minnesota We offer tools and training for employment and for helping seniors remain independent and active. As Minnesota’s accessible reading source we also transcribe books and other materials into alternative formats, including audio and braille. We assist Minnesotans who are blind, DeafBlind, losing vision, or who have another disability that makes it difficult to read print. I hope you find what you need here. We've also created a Tips for Using Our New Website page. If you’d like to apply for services, learn more, or have more questions, just give us a call. You’ll find contact information for all of our offices on our contact page, or you can call our main office at 651-539-2300.   2018 Summer Opportunities for Teens Learning skills related to blindness, low vision, and DeafBlindness The programs listed below are of varying lengths during the summer. They offer training in independent living and job readiness skills. The program descriptions that follow are taken from each organization’s website. If you’d like to pursue any of these opportunities, please speak with your SSB counselor:   BLIND Incorporated  (Blindness: Learning in New Dimensions) offers an 8-week Post-secondary, Readiness, Empowerment Program (PREP) designed to prepare students for academic, employment, and social success.  The PREP curriculum is designed to empower blind youth with the alternative techniques of blindness they will need to be successful in the college and the career fields they choose, and to give them the confidence and belief in themselves they need to find and keep a job. Additionally there are three one-week summer programs focusing on independent living, post-secondary success, and navigating the world of work.      Career Ventures, Inc . offers resources in: Job Seeking Skills training, Volunteer opportunities, Paid-work experiences, Job Shadows, Internships (on a case by case basis), Job Placement, and Job Coaching. Contact Wendy DeVore at wdevore@careerventuresinc.com for more information.   Courage Kenny SHARE Program  is a resource that provides people of all ages and abilities the opportunity to achieve physical and emotional fitness - and just have some fun. SHARE is a service of Courage Kenny Rehabilitation Institute, part of Allina Health, but our list of services includes those offered by other organizations. It's a one-stop shop for activity listings and registration details in Minnesota and western Wisconsin.    Duluth Center for Vision Loss  offers summer camps designed to sharpen skills needed for success, including Workforce Readiness, College Readiness, Self-advocacy, Mobility, Technology, Independent living, and much more. Students will learn core workforce readiness and adjustment to blindness skills.  They will also be given the opportunity to socialize with peers from across the state and to participate in a wide array of recreational activities. The Lighthouse Transition Program is built on the understanding that “now is the time” that youth need to be developing certain core skills that are essential for their future    Helen Keller National Center  offers programs to students who are DeafBlind which enable each person who is deaf-blind to live and work in his or her community of choice. HKNC offers individualized evaluation and training which will assist students in achieving their own definition of success. The emphasis for the student in the program is to participate in learning opportunities which will lead to successful employment and a full, enriched and independent life in the community. The philosophy of the Center is one of self-determination for all.   Minnesota State Academy for the Blind  (MSAB) offers Summer School programming for elementary, Middle school and high school age students.  Elementary School programs focus on elementary level academics as well as individual goals identified in student IEP’s. Middle and High school students will participate in activities encompassing the three areas of transition (postsecondary, employment, and independent living).  National Federation of the Blind offers of variety of local and national opportunities. The NFB BELL Academy is designed to provide intensive Braille instruction to blind and low-vision children during the summer months. EQ is a week-long learning opportunity that gets blind students excited about STEM by offering hands-on learning experiences. Visit www.nfb.org and www.nfbmn.org for more information.    Stone Arch Employment Solutions, Inc. Email Cori Giles at cori.giles@comcast.net for information.   Summer Transition Program (STP) provides experiences to address the specific transition needs of students who are Blind, Visually impaired or DeafBlind. STP complements each student’s core curriculum at their local school by providing individualized opportunities in the three transition areas identified in their Individualized Education Program (IEP). These unique transition activities, as part of the Expanded Core Curriculum, give each student the opportunity to increase independence in their school, home, community and work environments. Dates for 2018 are June 13-25.  Email Julie Kochevar at julie.kochevar@ahschools.us for information.   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.   Transcript   Take Full Advantage of Transition Services: Enhancing Opportunities for Success - Meet Kylee Jungbauer (Transcript Provided) Kylee: State Services for the Blind can be included in on that plan but then we will also have an employment plan for the students as well. Jeff: Kylee Jungbauer, Rehabilitation Counselor for Transition Age Students. Kylee: We like to keep our students busy during the summer, that's what I tell all of my students so yep, if you're working with us we expect that you're working your plan and obtain that job goal. Jeff: Voices from the success stories of transition age students. Student 1: State Services for the Blind played a role in helping me figure out, for one thing what I wanted to do after high school, and then where I wanted to go to college, and then also they assisted me with helping me find a job. Student 2: Training in stuff relating to technology and all your use of computers and phones, what's the best way that works for you. Student 3: So I was very lucky to have an IEP team that was familiar with working with a blind student. Jeff: Learn about the transition unit at State Services for the Blind. Kylee: I think another way a parent can be involved is just to have that expectation of their student that they will work, and have that expectation that okay yes, they need to learn how to cook, how to do their own laundry, how to clean because the parents aren't gonna be around forever right. Jeff: Kylee is part of a team at State Services for the Blind in their transition unit. Be sure to contact your State Services and find out what their transition team can do for you, and for more podcasts with the blindness perspective, check us out on the web at www.blindabilities.com, on Twitter at Blind Abilities, and download the free Blind Abilities app from the app store, that's two words, Blind Abilities. Kylee: But I think more importantly, is taking a step back and saying, okay, do you have the skills to actually go to college, do you have you know, the advocacy skills, do you have the technology skills, do you have the technology that you actually need? Jeff: Kylee Jungbauer. Kylee: Yep. Jeff: Is that right? Kylee: Yep, yep. Jeff: Welcome to Blind Abilities, I'm Jeff Thompson. Transitioning from high school to college to the workplace, it's a journey that most of us have taken, or some of us are looking forward to, and we'll be talking to Kylee Jungbauer. She's a transition counselor at State Services for the Blind. Kylee is going to talk about the services that you can receive to enhance your opportunities whether in college or gaining employment in the workplace. She's going to talk about the transition unit at State Services which will help you navigate your transition journey and make available all the resources, training, and skills, and confidence that you'll need for the journey. Kylee welcome to Blind Abilities how are you doing? Kylee: I'm great, how are you? Jeff: I'm doing good thank you. I really appreciate you taking the time to come down to the studios to share with us what you do for clients of State Services for the Blind. Kylee: Yes of course. Jeff: So Kylee, what is the transition unit at State Services for the Blind? Kylee: We work with youth about 14 to all the way up to 24, so college students as well, and we help them move through their transition from high school to either college or high school to just starting off with their first couple of jobs, we look at what their job goal is, or if they don't have a job goal, bringing them to that, with looking at different interest, inventories, or getting different work experiences so they can try different jobs and see what they really like. Jeff: When you say 14 to 24, so 14 you're talking about students who are in high school? Kylee: Correct yep, so when they're in high school we work with in conjunction with their schools and their TBVI's to supplement what they're already getting or maybe give suggestions, expose them to some different technology, and things that maybe they aren't getting in their school. Some schools provide a lot of adjustment to blindness training, and some schools do little, so we like to supplement especially during the summer when they're out of school. Jeff: And why is that? Kylee: Just to get them prepared for life, like I said transitioning out of education, you know high school, a lot of the services are provided for them, they aren't really having to advocate hopefully too hard for those services versus when they're an adult, they're kind of on their own and they have to learn how to do those things and advocate either in college or in their first jobs. Jeff: And what kind of options are there for the summer? Kylee: We have a lot of summer programming that some of it we provide, a lot of it the various vendors provides anywhere from more social to adjustment to blindness training, where, you know learning Braille, learning orientation mobility skills, a lot of Technology in Duluth, since it's so far away they have some online courses where you can work with them remotely I guess from anywhere in within Minnesota, so there's a lot of different options. Jeff: When you were talking about the TVI's teachers for the visually impaired, you're talking about the district teachers? Kylee: I don't know if they're considered district teachers or not but the district's hire them, yeah the schools provide that service. Jeff: And that's where they start their individual educational plan. Kylee: Yep yep, the TBVI's, they're included in it, the students will also have a case manager that kind of runs the whole thing and makes sure that the goals that are written on the education plan are being obtained or maintained or changed as needed, and State Services for the Blind can be included in on that plan but then we will also have an employment plan for the students as well with their job goal, or if there isn't a job goal then we, we just put something generic while we're exploring different careers. Jeff: So they actually have a simultaneous education plan segueing into a employment plan? Kylee: Correct yep, they'll have an education plan and an employment plan at the same time up until graduation of course, and then it will just be an employment plan with State Services for the Blind, and that will bring them through either their first job or college. Jeff: Well that's a good segue. Kylee: Yeah. Jeff: How does State Services or the transition work with the districts or the Department of Education in Minnesota? Kylee: We like to be invited to all of the IEP meetings so please invite us, that doesn't always happen, just because sometimes they get thrown together really last minute and as long as the parent and the student can make it they kind of just go on with it but, it's good for us to be there so we can see what the school is providing and maybe advocate for more, maybe make suggestions, or see where we can supplement in during this school year, you know sometimes students have time on weekends or after school, or especially during the summer time when they're on break. We like to keep our students busy during the summer that's what I tell all of my students, so yep if you're working with us we expect that you're working your plan and obtain that job goal throughout the school year and then especially during the summer when you're on break and you have that extra time, Jeff: Are there internship programs available to transition-age students in the summer? Kylee: Yes definitely we can work with a vendor but we also have our work opportunity navigator, Tou Yang, and he works with a lot of the students that I'm working with to get them internships, paid summer jobs, if they're interested in working during the school year that's great too, or doing Job Shadows so they can check out different jobs. Some students have this career goal, they know they want to do it but they haven't really talked to somebody who's in the work field actually doing that job, and they may find that oh it looks like it's a lot more data entry and paperwork versus client contact and so maybe they don't want to do that, or maybe they want to be a photographer but they don't want to have to figure out their own taxes or anything like that, so they'll look into working for a company versus going out on their own. So different things that they just don't know because they haven't had that experience. Jeff: Experience that will help them formulate their career goals. Kylee: Right exactly, yep so each career goal on our end has to be looked at, explored, and we have to determine if it's feasible, so if we have a student who wants to be a dolphin trainer for instance but doesn't want to leave Minnesota, that's probably not going to be something that SSB will support just because once they graduate you know, they won't be able to find a job here in Minnesota, so yep. Jeff: Maybe moose training or something but not dolphin training. Kylee: Yes. [Whoosh Sound Effect] Jeff: So if someone wants to explore a career, is there a resource here to help them do that? Kylee: Yep work with Tou, and also we've got a couple different websites that we can either send to our students or sit with them and work one-on-one with them to do some exploration that way, and hopefully the student are getting that in their school as well, hopefully. Jeff: So Tou, you say he's the employment navigator, he actually contacts companies, works with companies to know what they want and educate them on what to expect probably, and then brings people in for opportunities? Kylee: Yep, yep he has a background in working and doing job placement for other companies in the past so he has those employer connections which is great as well, but yep he brings students out to look at people out doing the actual job that they may be interested in so they can see the intricacies of it and still interested in that after learning the ins and outs or if maybe it's not for them and they want to explore other options. Jeff: So Kylee, how do parents get involved, do you have contact with parents of transition students? Kylee: Definitely, parents can be as involved as they want to be of course if their student is a minor, they have to be there for any signing of documentation, but after that they can be as involved as they want to be, kind of feel that out with both the student and the parents. Sometimes I just meet with my students one-on-one during the school day or whatever is convenient for them, but sometimes the parents want to be there, sometimes I can send an email to the parents after a meeting just giving them a recap. If I'm sending internship opportunities or things that need to be filled out with the student and maybe the student isn't the most responsive, I'll just CC the parents on the email just to make sure that everybody saw that it needs to be sent back. But I think another way that parents can be involved is just to have that expectation of their student that they will work, and have that expectation that, okay yes they need to learn how to cook, how to do their own laundry, how to clean, because the parents aren't gonna be around forever right, and they also hopefully won't be following their student to college, so if they need those skills just like any other person. But on the flip side of that, we understand that for a college student, or college bound student it is normal for them not to have those skills. I think college bound students kind of figure out how to do their own laundry once they show up and they dye a white shirt red for the first time and then they're like, okay maybe I need to figure this out, so that's totally normal but I think yeah, for parents to have that expectation that their students work and most people I know had to have a summer job so they could pay for their gas, pay for their the clothes that they want, or the new phone, or you know what have you, so yeah just having that expectation that their student will go on in transition just like any other visual person, so yeah. Jeff: You brought up a good point about you know, the parents are probably their first advocate that they have coming along in life, and there's comes a point in that transition process where a student has to start considering taking over that advocacy, advocating for themselves, like when they don't get a book on time that they can't always depend on their TBI or disability services, they get to a point where they start to have take responsibility for laundry like you said, all that stuff. Kylee: Yep yep, we have a whole Student Handbook that we go through and it has expectations of you know all the documentation that we need before semester starts, but I think more importantly is taking a step back and saying, okay do you have the skills to actually go to college, do you have you know the advocacy skills, do you have the technology skills, do you have the technology that you actually need, the knowledge of the different apps, you know to get your books online, right now it's Jesse that's working with all of our students, but getting our transition tech involved and they come in for a tech assessment to see what they have right now and what they'll need with both technology and technology training. So I have a student right now we're getting her tech package in but also we're planning for the training that she'll need in preparation for going off to college because surprisingly, her typing skills aren't that great, so that's something she knows she really needs to work on because all of those papers that she's gonna be writing, she's gonna need those skills, yeah super exciting, skills that you'll need right. [Whoosh Sound Effect] Jeff: I've seen reports where like colleges said that people are coming in and they're not prepared, and I've also seen where people come in but they end up being like a week or two behind because they're just trying to use this new technology that they don't understand yet and you have to be able to hit the ground running when you enter college. Kylee: Right yes, I talk a lot about that you know, college is high school times ten, you know you don't have a whole week to learn about one chapter in a book, and then have a test on it maybe a week later, it's like five chapters in one week, so you have, yeah right exactly, you have to be able to hit the ground running. So making sure that they're connected with the disability services at their college and they know the ins and outs of how they ask for accommodations, if they need extra time with test taking, anything like that, knowing how to get all that stuff before they go into college. I talked to my students about how some teachers are fabulous with accommodations and some just don't want to deal with it, or they haven't really had to deal with it in the past, so having those advocacy skills are huge. Jeff: Yeah I always suggested when I went in, I learned right away that, send in an email to each teacher, each professor, six weeks in advance if you get that opportunity, to start setting up that communications, and get that underway, rather than trying to set something, because everyone's busy that first week. Kylee: Definitely yeah. I know when I went off to college for the first time, I was terrified to talk to any of my professors, but you don't have that you know option when you need accommodations, you just have to go for it, and feel you know, be comfortable, or maybe you don't have to be comfortable with it, but you have to be able to at least do it, so yeah having those skills is huge. Jeff: Yeah and it does get more comfortable, and as long as you do get comfortable with it, it just puts it back, you just move forward from there. Kylee: Right exactly. Jeff: What words of advice for someone who is transitioning from high school to college to the workplace? Kylee: I would say make sure that you have all of your technology training down, your orientation and mobility, make sure that you're comfortable with that. I think a lot of students are comfortable in their school settings, so some that have some vision may not even use their cane, but I think it's important when you're out in public especially when you're learning new locations to have those orientation mobility skills down, because yeah you will need them. Advocacy skills as well because you need to be able to talk to your employer and let them know what you need and feel comfortable with that, yeah it's very important. Jeff: Yeah because most colleges aren't that one building school. Kylee: Exactly yep, and a lot of the students that I work with we offer orientation mobility skills, multiple semesters so they can learn their new path, you know each time. After a student's been on campus for a couple of years they pretty much know the layout but, I have no problem each semester bringing in orientation mobility, you, just right away so they feel comfortable with where they're going. Jeff: Well that's great, Kylee how does someone get in contact with State Services for the Blind for the first time? Kylee: The best way to do it is to contact, if you're in the metro to contact our St. Paul office, and they will get you connected with Meredith Larsen, and Meredith does all of our orientation and intakes, and orientation is provided twice a month at different times, so you can come in, learn about all of our services and decide if this is the right program for you. If so then she'll meet with you one-on-one and do an intake and have you sign an application at that point and that kind of, your signing saying yes I'm dedicated to this program, and then from there you'll start working with a counselor. If your you're in the metro it'll be either me or Ashlyn, and if you're in Greater Minnesota there's different counselors out in those areas that also work with our transition youth. Jeff: That's perfect, well Kylee, once again thank you so much for taking the time out of your day to come down to the studios here and sharing with us, believe me it's been a wealth of information, so thank you very much. Kylee: Yep, thank you. Jeff: It was a real pleasure talking to Kylee and be sure to check out the show notes where you can find out how to contact State Services for the Blind, and you can find the summer programs that are listed, and some job opportunities you could have for helping out at the summer programs, and to contact State Services in your state be sure to check out AFB.org where they have resources where you can find the services offered in your state. This podcast is produced in part by State Services for the Blind, live, learn, work, and play. [Music] And a big thanks goes out to Chi Chow for his beautiful music, and that's LChiChow on Twitter. Thank You Chi Chow. Once again, thanks for listening, we hope you enjoyed, 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 the realities of Blind Abilities. For more podcast with the blindness perspective, check us out on the web at www.blindabilities.com, on twitter at BlindAbilities, download our app from the app store, Blind Abilities, that's two words, or send us an email at info@blindabilities.com, thanks for listening.

Who is the best hitter of all time and what's wrong & right with baseball? In depth interview with Brett Boone.