Podcast appearances and mentions of reuben strayer

What defines the unique mindset of an emergency clinician? It's not just the fast pace or the chaotic environment—it's the deliberate, top-down thinking that prioritizes patient safety over diagnostic certainty. This approach, though deceptively simple, often flies in the face of traditional medical training, which emphasizes comprehensive differentials and exhaustive workups. In emergency medicine, knowing what the patient needs often matters more than knowing exactly what they have. In this episode, we explore the emergency medicine mindset, the pitfalls of the bottom-up approach, and why experienced clinicians focus on acute interventions and dangerous conditions. Finally, we discuss how humility and strategic communication with patients can make all the difference in mitigating risk and building trust.

In this Part 2 of our 2-part podcast series on How EM Experts Think with Dr. Reuben Strayer, Dr. Mike Betzner and Dr. Scott Weingart we dive deep into the nuances of practicing smarter, faster, and better in the ED. We answer questions like: How should we employ hypothetico-deductive reasoning in our daily practice of Emergency Medicine? How can we best streamline thorough data gathering for each case so that we don't miss key data points? How do the master EM clinicians perform an efficient and targeted history and physical exam? How can the concept of heuristic cycling help you avoid outdated or faulty thinking? How can we document our clinical encounter in a way that considers a differential diagnosis that prioritizes dangerous conditions and improve our thinking around cases? How can we use the 2-10% rule for pre-test probabilities and the concept of preferred error to guide our decision making for tests and treatments in the ED? What strategies can we use to avoid anchoring bias and keep your mind open to all possibilities? What's the role of shared decision-making when navigating diagnostic uncertainty? How does understanding the vigilance pendulum help us assess our risk tolerance better? How can post-shift decision journaling, conducting pre-mortems and meditation improve our decision making and boost our emotional resilience on shift? and many more... Please consider a small donation to EM Cases to ensure ongoing high quality FOAMed: https://emergencymedicinecases.com/donation/

Which elements of your current pre-shift preparation contribute most to your mental clarity and performance, and what new practices might further optimize your readiness? With interruptions shown to increase task errors and decision fatigue, how can you strike a balance between being approachable to colleagues and safeguarding your focus for patient care? When confronted with a particularly challenging or emotionally charged case, what strategies have you found most effective for maintaining professionalism and clear decision-making under pressure? How often do you debrief after high-stakes scenarios, and what impact has debriefing—whether formal or informal—had on your team's learning, emotional recovery, and future preparedness? What strategies do you use to foster open communication and ensure all team members feel empowered to provide input during high-stakes situations? How do you mentally and emotionally shift from managing a critical resuscitation to treating lower-acuity patients without compromising your focus or energy? When faced with a complex case where diagnostic clarity is elusive, how do you prioritize your next steps while maintaining confidence in your decision-making process? How can apps, personalized workflows, or EMR tools be better utilized to minimize cognitive load and enhance clinical decision-making during shifts? These are just some of the questions we pose in this 2-part podcast series on How the Experts Think with Dr. Reuben Strayer, Dr. Scott Weingart and Dr. Mike Betzner... Please consider a donation to ensure EM Cases continues to provide you high quality Free Open Access Medical Education here: https://emergencymedicinecases.com/donation/

In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Reuben J. Strayer, MD, author of the May 2024 Emergency Medicine Practice article, Current Concepts in Ketamine Therapy in the Emergency DepartmentDiving Into Ketamine Use in Emergency MedicineUnderstanding Ketamine: From Origins to Emergency UseExploring the Ketamine Brain ContinuumKetamine Dosing and Administration TechniquesCombining Ketamine with Neuroleptic MedicationsPractical Approaches to Ketamine for Pain ManagementInnovative Pain Management and Ketamine UseProcedural Sedation with Ketamine: Techniques and ConsiderationsAddressing Agitation and Sedation in Emergency SituationsNavigating Intubation Strategies: DSI and Ketamine-Only ApproachesKetamine's Role in Treating Asthma, Status Epilepticus, and Alcohol WithdrawalExploring Ketamine for Treatment-Resistant DepressionConcluding Remarks on Ketamine's Versatility in Emergency Medicine

In emergency medicine we use a top-down approach. What does the patient need? Not, what does the patient have?4 Responsibilities of the Emergency Physician:Resource stewardship - Not a lot of control over this variable Customer service - Evidence based medicine doesn't equal good customer service. You must be able to communicate well with your patients and manage expectations appropriately. Symptom relief - Don't forget to address the pain or symptom that the patient came in for while thinking through DDX and orders. Patient safety - Most of our time is spent here. Patient safety is resuscitation and identifying dangerous conditionsDr. Strayers system:Identify patients needing resuscitation and triage appropriately Identify dangerous conditions using HPI, physical exam, testing. This list is narrowed down by each step in the process.  Have a plan for a negative workup as a positive work up will usually dictate a plan on its own.Run the board frequently and after seeing new patients. Place orders before chartingManage interruptions with a method that works for you. Multitasking isn't possible.Expand work up if the HPI and physical exam are limited. Huge thanks to Reuben Strayer! Check out his website EMUpdates.comSupport the show

Thank you to Reuben Strayer for allowing me to reproduce his awesome content here. Check out his website at emupdates – return if worse for more emergency medicine content. Email me with comments or questions at Aaron@PracticalEMS.comQuick tips:Resuscitation Does the patient need resuscitation? - Vitals- AMS-Neuro deficits- Sick appearing- Threat to self or othersPrioritize patient appropriately and/or call for appropriate resourcesIdentifying dangerous conditions- This is most of our ED patients- Review RN/triage notes before seeing patient- Prior visits/discharge summaries/ems runsheet- Ask "What medical problems are you known for?"- Ask for changes in medications-  Med non-compliance - Social questions- Ask last "Why have you come to the ED on this fine evening?"- Have you ever had these symptoms before?- Plan: what else need to be ruled out with imaging/lab work?- Plan on what will happen with negative results, before they come back- Positive results will usually dictate the planRun your board frequently - What are we waiting on?- Patient improving or getting worse- Should I offer update, food, pain meds- Update charting- Always place orders before chartingFind a method for managing interruptions that works for youIf HPI and physical exam are difficult or limited - expand your work upDon't make waste basket diagnosis such as costochondritis, gastroenteritis, GERD, anxietyFollow key casesSupport the show

In this month's EM Quick Hits podcast: Anand Swaminathan on GI balloon tamponade preparation and indications, Jesse McLaren on why troponin is rarely useful in SVT, Christina Shenvi on why we should not use the term "mechanical fall" in older patients, Nour Khatib & Jonathan Wallace on rural vertical vertigo case and Reuben Strayer on VAFEI - Video-Assisted Flexible Endoscopic Intubation for the anatomically challenging airway... The post EM Quick Hits 40 – GI Balloon Tamponade, SVT and Troponin, Falls in Older Patients, Vertical Vertigo, VAFEI Airway appeared first on Emergency Medicine Cases.

Reuben Strayer and Duncan Grossman discuss all things airway. Specifically, how the introduction of many airway technologies at once–some of them revolutionary, some not–have confused our airway strategy. So how can we incorporate the best of these technologies into contemporary airway management? They begin with a big question – what equipment should you choose? There are many options, including direct or video laryngoscopy as well as multiple versions of the laryngoscope blade itself. As Reuben explains, all these terms can be confusing and are often imprecise. Direct laryngoscopy clears a line of sight between one's eyes and the glottis to visual it. This is unlike video laryngoscopy which uses a camera to visual the glottis. The next distinction is the type of blade – standard geometry versus hyperangulated blades. The differences between - and the varying uses of – standard geometry blades and hyperangulated blades are discussed. This discussion will clear up confusion about the nomenclature for all clinicians. The long and the short of it is that a camera can be attached to both standard geometry and hyperangulated blades allowing video laryngoscopy with both. It depends on the clinician's comfort and training as to which one you will reach for. However, using a hyperangulated blade does make viewing the cords easier. The hyperangulated blade also requires less force, which is favourable in instances of cervical spine injuries or tongue masses. But, there are downfalls, and Reuben takes us through what to expect. The standard geometry blade on the other hand is faster, and easier to utilise suction. It is also easier to use a bougie when using a standard geometry blade. Moreover, the standard blade video laryngoscopy uses the same skill set as a direct laryngoscopy and this is beneficial for new learners. With all the new, wonderful technology available to us, should trainees bother learning traditional techniques? Reuben contends they should for a few reasons. The first being that technology is fragile and can let you down at any moment. The second being that standard geometry video laryngoscopy contains within it the older technique – just with the addition of a video. Therefore, the way to get good at direct laryngoscopy is by getting very, very good at video laryngoscopy. Jump onboard and join Reuben and Duncan as they provide a masterclass on airways. For more like this, head to our podcast page #CodaPodcast

In this month's EM Quick Hits podcast: Brit Long on Surving Sepsis Campaign -2021 Updates, Nour Khatib on rural medicine case - angle closure glaucoma, Reuben Strayer on bougie vs endotracheal tube and stylet on first-attempt intubation, Justin Hensley on management of frostbite, Sarah Foohey on the hot and altered patient, and Andrew Petrosoniak on central cord syndrome... The post EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome appeared first on Emergency Medicine Cases.

In the Emergency Management of Chronic Pain podcast, Duncan Grossman and Reuben Strayer discuss how and why patients with chronic pain present to the ED. Managing patients with chronic pain is challenging and often it feels like these patients present to the ED during every shift. But… is it as common as it feels? Statistics suggest that 20% of American adults suffer from chronic pain. Why? Well, opioids are both the disease and the cure. Opioids are effective for managing acute pain. However, when they are used for (even) more than a couple of days they can start to cause pain. Therefore, we have to understand the spectrum of opioid benefit vs harm. Reuben and Duncan discuss a framework that accounts for the relationship between chronic pain and opioid use. Noting that each patient presents a unique challenge. Take for example, the patient who is on daily, low dose opioids but is otherwise unaffected by their pain medication. Or, the patient who has chronic pain but doesn't take opioids. We need to be careful here as these patients can be more susceptible to developing an addiction from prescribed opioids due to their ongoing pain. What about the patient who takes opioids daily but is buying them off the street... Reuben takes us through some strategies for helping all of these patients. One such strategy is to talk to the prescribers. We need to help these patients by encouraging their prescribers to take the reins and to move the needle from opioid harm to opioid benefit. Tune in as Duncan Grossman grills Reuben Strayer on chronic pain in patients, how to manage them and how to help them. For more like this, head to our podcast page #CodaPodcast

In this month's EM Quick Hits podcast: Anand Swaminathan on lateral canthotomy, Emily Austin on pediatric cannabis poisoning, Reuben Strayer on an approach to hyperthermia, Brit Long on diagnosis and management of malignant otitis externa, Jesse McLaren on ECG diagnosis of occlusion MI in patients with BBB and Peter Brindley on prone CPR... The post EM Quick Hits 24 Lateral Canthotomy, Cannabis Poisoning, Hyperthermia, Malignant Otitis Externa, BBB in Occlusion MI, Prone CPR appeared first on Emergency Medicine Cases.

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in...

This is part 2 of the special podcast featuring Reuben Strayer, sharing his first hand experience of the COVID-19 situation in New York with Ashley Liebig, the medical operations commander for the Travis County and a flight nurse. "There was only a brief period between when we first started noticing coronavirus and when seemingly everyone in the city had coronavirus", "emergency providers are working in an environment that resembles a lake filled with coronavirus".

This is part 1 of the special podcast featuring Reuben Strayer and Ashley Liebig, sharing their first hand experience of the COVID-19 situation in New York. "So many people in the region got infected at the same time, long before we were paying any attention to it. And as the patients got sicker, we started to notice a few things, such as this was oxygen deficit we never seen before".

Since people began getting sick from COVID-19, there's been concern about having enough medical supplies of all kinds, including ventilators for very ill patients. While no one wants to be in a position where we need a ventilator, many of us don't know the risks that come with being placed on a breathing machine. And as we learn more about how to treat the coronavirus, some preliminary evidence suggests that in some patients ventilators have done more harm than good. Dr. Reuben Strayer has seen this phenomenon up close. He's an emergency physician and associate medical director at Maimonides Medical Center in Brooklyn, New York, where COVID-19 has taken hold. He himself has COVID-19, and as an expert on managing critically ill patients with airway and breathing problems, he is the perfect expert to answer the question "What do I need to know about ventilators in light of COVID-19?"

In today’s update: New York experience with fluid restriction in COVID ARDS, prone positioning for non-intubated hypoxic patients, resetting the intubation threshold, and using ABGs. Your questions for Reuben Strayer and Patrick Reinfried. For all the previous COVID podcasts plus a bunch of other super useful stuff, here is our depository of resources.  The below is not an evidence based approach, it is experience based and “here’s what we’re doing and it seems to work.” It is by no means the only way to go about this and there are certainly other shops proceeding differently with COVID-19 patients.   New York Experience Steven Johnson, DO and Dana Gottlieb, MD surveyed their hospital's docs for lessons they’re learning. Below are some of the recommendations. A full write up can be found at the EM Pulse Blog.    Ease up on the fluids Don’t give fluids unless you KNOW they are hypovolemic (diarrhea, vomiting, no drinking x 1 week). These patients seem to be very sensitive to fluid overload. Patient’s on the floor are avoiding intubation by keeping them net negative despite tachycardia and AKI. Consider starting the patient on a low-dose pressor rather than a fluid bolus to support MAP if they are on the verge of intubation due to hypoxia.  A suggestion for undifferentiated ED patients: if they are normotensive DO NOT give a fluid bolus. Patients that are hypotensive, carefully consider very small fluid bolus vs pressor (especially if clinically volume overloaded). Do not fluid resuscitate to clear lactate. The elevated lactate in a non-hypotensive patient is not from hypovolemia, this is likely from catecholamine surge from severe hypoxia and respiratory distress.  Not that any of us normally do….but DO NOT start maintenance fluids. It's interesting how the pendulum swings with IV fluid. Over the past few years, there has been a call to action to be more judicious with our fluid administration, especially in septic patients rather than reflexively jumping in ‘whole hog’ with 30 cc's per kilo (or even more).  Much of this is going to fly in the face of policies or benchmarks so it’s something to discuss among your group to see how you want to approach it.   Adding further support to COVID ARDS fluid resuscitation, Josh Farkas has this to say in his online Critical Care Textbook. (direct quote below) The cause of death from COVID-19 is nearly always ARDS – which may be exacerbated by fluid administration.   Gentle fluid administration could be considered for patients with evidence of hypoperfusion and a history suggestive of total body hypovolemia (e.g. prolonged nausea/vomiting and diarrhea). An aggressive fluid resuscitation strategy in viral pneumonia is especially misguided.  The primary life-threat facing these patients is ARDS (not hypoperfusion, and certainly not hypovolemia).  Perfusion can generally be easily maintained with early administration of low-dose vasopressors and a conservative fluid strategy if necessary (although most patients with viral pneumonia have adequate perfusion to begin with).   Notably, if hyperlactatemia is being driven by dyspnea causing sympathetic activation, this will only be exacerbated by fluid (which will worsen the respiratory failure).     Oxygenation and Prone Position Mechanical ventilation can go on a long time and intubated patients have not been doing well. Whether that’s a cause (mechanical ventilation has harmful effects),  an association (if you’re sick enough to get intubated, mortality is already high), or both remains to be seen.  These people are needing 15+ days of intubation, saving a vent for several days is meaningful. Unfortunately, every patient on the floor is developing severe hypoxia. Currently they are recommending a NRB at 15L with a NC at 10L underneath with persistent sats

In this episode I speak with Dr. Reuben Strayer, emergency physician at Maimonides Medical Center in Brooklyn, NY. The news is rife with reports of New York’s escalating COVID-19 cases and there are lessons we can learn from how they are responding.  Discussion includes Managing a massive surge (which is only going to get worse) Ventilator allocation planning Hot/Warm/Cold zones High Flow Nasal Cannula O2 for preox Use (or non use) of non-invasive ventilation Variations in COVID presentation COVID and cardiac arrest In harm’s way when PPE runs out   In one week, Strayer’s ED went from seeing 300-400 patients/day with a variety of complaints to 200-300 patients/day, HALF afflicted by COVID-19.  His department is split into 3 zones:   Acute care hot zone --  For COVID patients who need resuscitation and/or aerosol-generating procedures. Providers wear the highest level of PPE. Acute care warm zone --  For COVID patients who don’t need aerosolized procedures. Lower level of PPE. Cold zone -- Subacute area for people suspected NOT to have COVID. Lower level of PPE. Providers wear N95 masks under a surgical mask with goggles, even if seeing ankle sprains or working at their desk. “Wearing good but not perfect PPE is far better than wearing no PPE.” PPE is reused, in hopes of not running out. For the past few weeks, providers have used one N95 mask per shift. If they had been using N95s as single use devices, they would have run out long ago. Every effort is made to minimize exposure to viral particles. This means keeping the N95 on under a surgical mask as long as they can. Reuben’s thoughts on COVID and cardiac arrest. Is resuscitating these patients worth the risk?  If the patient codes in the ICU due to COVID pneumonia, further resuscitation should not be done since there is nothing additional to offer that patient (other than ECMO), If an unknown, undifferentiated cardiac arrest patient comes to the ED, treat the patient as you would anyone in arrest, but use maximal PPE. A potential modification to your arrest algorithm is to place an LMA (with a filter if you have one) rather than doing bag-valve-mask ventilation. BVM is thought to be more aerosol-generating. How deeply should we put ourselves in harm’s way if we run out of PPE? If you don’t have any PPE, then you shouldn’t expose yourself to heavy doses of the virus. You can argue that it’s unethical and irresponsible to refuse to provide care to patients because you deem your PPE to be imperfect. Contrary to this, some describe the COVID+ patient as akin to a disaster zone and you only enter a zone when the scene is safe. If you enter without PPE, that is not a safe scene.  Strayer believes that we can avoid completely running out of PPE by reusing the PPE that we have. This means using one mask per shift, bringing it home in a sealed bag, potentially bleaching it and reusing it. What should be our approach to non-invasive ventilation? Unless you have viral filters for the inspiratory and expiratory arms of non-invasive ventilatory machines, they are hazardous to use.  Without proper viral filtration, COVID virus will essentially be spewed into the atmosphere by these machines. If you have viral filters, non-invasive ventilation is an excellent option, especially if you have a dearth of ventilators. High-flow nasal cannula (HFNC) has been used with great success in managing non-crashing but dyspneic, hypoxic patients. HFNC has been helpful both to relieve severe dyspnea as well as to correct extreme hypoxia. It is too early to say how these patients will fare in the long run. But even if many ultimately require intubation, having an option for delaying intubation if ventilators are scarce is helpful. This can be delivered using a dedicated device with humidified HFNC capacity. The advantage is that you can titrate FiO2 and flow rate independently. Alternatively, you can use a conventional nasal cannula at the highest rate tolerable to the patient. COVID patients present in 3 ways to the ED: Mildly ill with a little dyspnea, fever, malaise, and no hypoxia.   These patients go home. Moderately ill with more significant dyspnea and hypoxia.  These are first put on nasal cannula O2. Most are admitted, but some improve to the point of being able to go home in a few hours. In the ideal world, you would send them home on home O2. If they fail nasal cannula O2, HFNC is started. Severely ill patients clearly need to be intubated from the outset. These patients are preoxygenated with nasal cannula and non-rebreather, unless they were already on HFNC and then they’re intubated with HFNC in place. Now that the surge has happened with COVID in Strayer’s ED, what has surprised him about how things are playing out? First, Strayer is confident that the surge hasn’t yet happened. He is anticipating “mountains of patients” and despite their aggressive preparation, he fears they are not going to have the capacity to care for everyone who’ll need it over the next month. He is surprised by how little PPE we have. It is astounding how quickly hospitals are getting to the point of needing to ration PPE to providers. He’s surprised by how few non-COVID patients have been coming to his ED. Patient volumes are dramatically down. Who is being quarantined in New York City?  New York officially disbanded quarantine for asymptomatic patients or providers. For providers with a positive COVID test, the policy is to stay home until you’ve been asymptomatic for 3 days and ≥7 days from the onset of illness. How are COVID tests being used? It’s been a roller-coaster. They went from having access to no tests, to very limited tests, to plenty.  When the testing capacity increased, they were testing lots of patients, and virtually all were coming back positive. Now they have reverted back to having limited (if any) tests.  Currently, only people who are sick are tested, and with the high prevalence of COVID in the community, the results are almost always positive and rarely helpful.  Are chloroquine or hydroxychloroquine being prescribed? Due to dwindling supply and insufficient supporting science, at Strayer’s institution hydroxychloroquine is only given to very sick patients and with ID approval. What is the protocol for ventilator sharing and/or rationing? Strayer’s hospital is enacting a shared ventilator policy. The question is how much COVID patients will be harmed by sharing a ventilator with another person vs. the benefit of sharing. They are  hoping that 1 ventilator can safely be used for multiple patients. New York State has developed a ventilator allocation guideline which Strayer simplified and shared on his blog.  The blog also includes a comprehensive intubation checklist.  The Ventilation Allocation Protocol has several steps: 1) Assess for exclusion criteria. Excluded are patients who’ve had a cardiac arrest, those who wouldn’t normally meet ICU admission criteria based on their prognosis (ie. metastatic cancer, severe dementia), those who are DNR/DNI, and patients who the provider believes has a condition that would severely limit the prognosis despite maximal care.  2) Assign priority:  blue, red, yellow, green.  This is based on a quantification of short term mortality using the SOFA score.  It considers a series of organ systems and uses surrogates for organ dysfunction as a way of determining short term mortality.  Blue (SOFA>11) -- Lowest priority for a ventilator due poor prognosis and being the least likely to benefit. Red (SOFA

In this special edition EM Quick Hits podcast, Drs. Eddy Lang, Salim Rezaie, Anand Swaminathan, Jonathan Sherbino and Reuben Strayer share their experience with the COVID-19 pandemic and offer some practical tips... The post EM Quick Hits 14 – COVID-19 Your Colleagues’ Experiences and Practical Tips appeared first on Emergency Medicine Cases.

We can't immediately change the process of medicine, the stuff that is kind of a drag and wears us down. What we can change, however, is our mindset. In this episode, we dissect several practices for shift preparation with a common goal of operating at a peak level of performance and experiencing more joy in what we do. Today we learn how to pregame, like a pro.   We discuss: When the process of practicing medicine becomes your purpose for being a doctor, you’re at risk for burnout, if not worse. [00:30] The system will not adjust to what you need right now.  You have to adjust yourself. [1:45] How accepting gratitude, and other small changes in mindset, can have a logarithmic return on investment. [4:50] The ways that many elite-level performers pregame.  They rely on their rituals for peak performance. [07:15] Physicians are elite-level performers who rarely have the time to mentally prepare for each day. [8:40]   How some doctors pregame (or not).... Mike Weinstock doesn't pregame [12:06] Clay Smith's pregame distraction [13:20] Joshua Russell's sequence of physical, emotional and mental prep [15:10] Sabrina Adams the BAFERD [18:00] Jaime Hope thinks of her 4 professional identities [19:10] Mizuho Morrison's 3 steps of self talk [21:40] Ran Ran biking to work. [24:20] Joe Dubois walks to work Chris Nickson walks to work Ross Fisher calms during his commute. Haney Mallemat uses mental visualization. Luz Silverio's pregame ritual is to arrive to work 15 minutes early to “chit-chat” with members of her team.[28:40] Alan Sielaff allows sufficient time before the shift to get prepared. [29:30]:  Dan McCollum starts the day mentally preparing with the 5 Minute Journal.[31:00]  Reuben Strayer mentally prepare for a shift by practicing mindfulness [32:50]  Salim Rezaie isolates himself from social media and email for at least 1-2 hours prior to each shift.[35:30]  Mike Mallin uses intermittent fasting to improve his focus, attitude, and endurance at work. [37:15]   Rich Hamilton treats a shift like it’s a competitive sport. [38:30]  Rob's 2 pregame exercises. [41:10]  Jocko Willink’s “Good” [44:06]    Learn More: https://www.stimuluspodcast.com/ Complete shownotes for this episode: https://www.stimuluspodcast.com/post/2-pregame-like-a-pro

We can't immediately change the process of medicine, the stuff that is kind of a drag and wears us down. What we can change, however, is our mindset. In this episode, we dissect several practices for shift preparation with a common goal of operating at a peak level of performance and experiencing more joy in what we do. Today we learn how to pregame, like a pro.   We discuss: When the process of practicing medicine becomes your purpose for being a doctor, you’re at risk for burnout, if not worse. [00:30] The system will not adjust to what you need right now.  You have to adjust yourself. [1:45] How accepting gratitude, and other small changes in mindset, can have a logarithmic return on investment. [4:50] The ways that many elite-level performers pregame.  They rely on their rituals for peak performance. [07:15] Physicians are elite-level performers who rarely have the time to mentally prepare for each day. [8:40]   How some doctors pregame (or not).... Mike Weinstock doesn't pregame [12:06] Clay Smith's pregame distraction [13:20] Joshua Russell's sequence of physical, emotional and mental prep [15:10] Sabrina Adams the BAFERD [18:00] Jaime Hope thinks of her 4 professional identities [19:10] Mizuho Morrison's 3 steps of self talk [21:40] Ran Ran biking to work. [24:20] Joe Dubois walks to work Chris Nickson walks to work Ross Fisher calms during his commute. Haney Mallemat uses mental visualization. Luz Silverio's pregame ritual is to arrive to work 15 minutes early to “chit-chat” with members of her team.[28:40] Alan Sielaff allows sufficient time before the shift to get prepared. [29:30]:  Dan McCollum starts the day mentally preparing with the 5 Minute Journal.[31:00]  Reuben Strayer mentally prepare for a shift by practicing mindfulness [32:50]  Salim Rezaie isolates himself from social media and email for at least 1-2 hours prior to each shift.[35:30]  Mike Mallin uses intermittent fasting to improve his focus, attitude, and endurance at work. [37:15]   Rich Hamilton treats a shift like it’s a competitive sport. [38:30]  Rob's 2 pregame exercises. [41:10]  Jocko Willink’s “Good” [44:06]    Learn More: https://www.stimuluspodcast.com/ Complete shownotes for this episode: https://www.stimuluspodcast.com/post/2-pregame-like-a-pro

Salim Rezaie on single syringe adenosine for SVT, Sarah Reid on pertussis pearls, Elisha Targonsky on management of hyperemesis gravidarum , Joe Nemeth on the utility of hypertension as a risk factor in EM, Justin Morgenstern on tramadol myths, Reuben Strayer on ketamine only breathing intubation (KOBI)... The post EM Quick Hits 13 – One Syringe Adenosine, Pertussis Pearls, Hyperemesis Gravidarum, Tramadol, Hypertension Myths, KOBI appeared first on Emergency Medicine Cases.

In this EM Quick Hits podcast we have Emily Austin on physostigmine for anticholinergic toxidrome, Walter Himmel on understanding nystagmus to differentiate central vs peripheral causes of vertigo, Rob Devins on the role of transesophageal echocardiogram in cardiac arrest, Jesse MacLaren on nuances in inferior MI ECG changes and aVL, Andrew Petrosoniak on a practical approach to blunt cerebrovascular injury and Reuben Strayer on choicebo... The post EM Quick Hits 11 Blunt Cerebrovascular Injury, Physostigmine, TEE in Cardiac Arrest, Understanding Nystagmus, Subtle Inferior MI, Choicebo appeared first on Emergency Medicine Cases.

SAEM RAMS Who's Who in Academic Emergency Medicine - Dr. Reuben Strayer by SAEM

From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.   Pearls: The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.   For patients  breathing room air, pulse oximetry can be used to monitor for hypoventilation.   Nail polish has minimal impact on the accuracy of pulse oximetry. If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.       “The respiratory rate is the most vital of the vital signs.”    Experienced doctors look at a patient who seems well, but understands that they’re not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately.  Since we don’t always have access to reliable respiratory rate, Strayer’s go-to vital sign is the oxygen saturation. “Reusable pulse oximeter probes are gross.”  One study found that even when these probes are cleaned by standard procedure, ⅔ had bacteria cultured from them. Strayer recommends using single use probes in your department. Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923. Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal.   Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect.   If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger. Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149. As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.   Significantly hypercapnic patients saturate less than 95% when they’re breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing. If you need to give supplemental oxygen, then use capnography to monitor respirations.   The pulse oximeter does so much more than provide oxygen saturation.     It provides the photoplethysmogram (PPG) which is a waveform that tells you the “mechanical” heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.   The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high).  The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF. Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670. van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972. What if you don’t have a reliable pulse ox tracing?   Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there’s a lot of ambient light. If you’ve corrected for these problems and you still don’t have a good tracing, you should be concerned that the patient is poorly perfused. One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status.   Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.   How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?   One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin.   The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning. The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead. Functionally,  it doesn’t seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger.  For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.   Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891 Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826   DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link. Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227

Dr. Reuben Strayer and Dr. Eric Ketcham discuss the management of patients with opioid withdrawal and initiation of buprenorphine in the Emergency Department for opioid use disorder patients. Dr. Strayer is the Associate Medical Director at the Department of EM at Maimonides Medical Center and author of EMUpdates.com. Dr. Ketcham is the Medical Director for the New Mexico Treatment Services program and is an emergency physician at the San Juan Regional Medical Center in New Mexico. Hosted by Dr. Michelle Lin

What is New York City style resuscitation? Reuben Strayer and Scott Weingart honed their chops in public hospitals in America’s largest city, where patients come from every country, speak every language, and manifest every physiologic derangement on earth. Preferring to ask neither permission nor forgiveness, Reuben and Scott have long challenged emergency medicine and critical care orthodoxy and developed lateral (though sometimes divergent) strategies in their approach to problems that arise in the care of the sometimes unwashed masses who tend to avoid presenting to medical attention until they’ve fallen off the Frank-Starling curve. Topics that may be discussed (or argued) include the use of epinephrine, the use of noninvasive ventilation, the management of recently intubated patients, the use of ketamine as an induction agent with and without a paralytic, and decision-making in badly injured trauma patients. Ad hominem attacks will be defined and probably employed. Though Weingart has a physical and intellectual disadvantage against the bigger, stronger, quicker, younger, and better-looking Strayer, these disparities will be muted by Natalie May’s capable moderation.

In anticipation of Episode 115 Management of the Agitated Patient, Dr. Reuben Strayer tells the story of the case that got him interested in developing an expertise around management of the agitated patient that includes an important simple pitfall and pearl about physical restraint. It that could prevent a death in your ED... The post BCE 75 Reuben Strayer’s Agitated Patient appeared first on Emergency Medicine Cases.

A no-holes barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.    Episode Guide In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17). Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain. A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects. Haloperidol is an analgesic option for patients taking chronic opioids. Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV,  5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose.  If that doesn’t work, he uses analgesic dose ketamine. For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum. Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses.  Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check. Check out Reuben's blog Emergency Medicine Updates and follow him on Twitter   References Opioid Hyperalgesia Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text link. PMID: 21412369  Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link.  PMID: 21029354 Droperidol for analgesia Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396.  PMID: 20832967 Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279 Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073 Early studies on Haloperidol for analgesia Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741 Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10. Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130. Haloperidol for pain Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669 Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990 Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034

Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.  "In the 7 years I've been administering ketamine for this application, I've never had a patient walk into my ER and ask, 'Can I get ketamine?'" - Sergey Motov, MD     Who gets low-dose ketamine for analgesia? Patients who fail initial 3+ opioid doses. Patients generally with chronic pain, neuropathic pain, oncology pain, opioid tolerance, polytrauma. Great medication for treating pain and doesn't have the same addictive qualities as opioids. Ketamine is abused, namely in China. In the United States, we don't see it as much. Low-Dose Ketamine Bolus Dose for Analgesia 0.3mg/kg in NS 100mL infused over 15 minutes (400mL/hr) Max dose 30mg **Reduces the feeling of unreality in comparison to administering IV push. Basically, your patient won't freak out! (at least much less episodes!)   Bolus Administration Pearls: No pumps are needed for the bolus dose administered as a short infusion. But doesn't hurt either. No monitors needed. Low-Dose Ketamine Drip Dose for Analgesia 0.1mg/kg as a continuous infusion Titrate every 30 minutes as needed - involve provider when titrating. 0.1-0.3mg/kg 0.4-0.7mg/kg --> you've now entered a recreational dose Preparation: Ketamine 100mg in NS 100mL = 1:1 ratio Infusion Pearls: Must use an iv pump to administer the infusion. Use nursing judgement for telemonitoring. Majority of patients will get discharged after 2-3 hours of continuous therapy. Look at the presentation of the patient. Not everyone will need an infusion. Many patients will find relief with the bolus dose alone. Some may need both the bolus and infusion. Dose obese patients with an ideal body weight. Logistics: Ketamine comes in 2 different concentrations: 10mg/mL and 50mg/mL Much easier to calculate and draw up ketamine with the 10mg/mL concentration with this application! Worried about waste? Pharmacy can keep a single dose vial with 10mg/mL concentration for 24 hours and use it as a multi-dose vial. They will have to prepare all of your ketamine bolus infusions and ketamine continuous infusions - wouldn't that be nice? Now Listen to the Episode... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 66(3). doi:10.1016/j.annemergmed.2015.03.004 https://www.ncbi.nlm.nih.gov/pubmed/25817884 Lee, E. N., & Lee, J. H. (2016, October 27). The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis.  https://www.ncbi.nlm.nih.gov/pubmed/27788221 Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – 7.  PMID: 28283340 Ketamine: How to Use it Fearlessly For All its Indications by Reuben Strayer. (2015, December 06).

Who is Reuben Strayer, MD? Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure A Special K Trip Part 3 - Ketamine for Analgesia & Tranquilization And now for the conclusion of the 3-part ketamine series with Reuben Strayer. Today’s episode is Part 3 focusing on Ketamine for analgesia and extremely uncontrollable violent patients. If you haven’t already, go back and listen to Episode 7 where Reuben talks about ketamine and how different dosing can have different applications in the ED setting. In Episode 8, Reuben talks about ketamine for PSA & RSI. Ready to continue with your Ketamine trip w/Reuben? Here we go! Ketamine for Analgesia Who gets ketamine? Chronic pain, poly trauma, oncology pain, etc. Dosing 0.3mg/kg 0.1-0.3mg/kg have been used. No pumps for bolus dose? No problem. Of course, administering through a pump will always be the gold standard. How to administer: Inject the analgesic dose into NS 100mL and infuse over 15 minutes. 15 minutes = 400mL/hr (best!) 10 minutes = 600mL/hr (not much difference) Why are we diluting the ketamine dose for administration? To prevent psychiatric emergence or your patient from "freaking out." Ketamine drips - always use a pump. (Not everyone will get a drip) 0.1mg/kg and titrated every 30 minutes. No monitoring required. *Use your discretion, if you feel that your pt needs monitoring - put your patient on a monitor and alert your provider. Some pretty good articles, full list below: Sergey Motov's article on ketamine for pain in the ED Cheryl Allen's article on administering ketamine in Pain Management Journal Sergey Motov interviewed on ketamine in EP Monthly Ketamine for Tranquilization Who gets it? Your huge guy where you have a small army of security and staff trying to hold him down and you are concerned for the patient's and staff's safety. How often are you using this? Rarely. Dose Dissociative Intramuscular (IM) Dose: 4-6mg/kg 500mg IM Adult dosing = approx. 100kg person Monitoring required with airway capable provider at bedside.  Safety Pearl for Violent and Agitated patients (whether you use ketamine or not): Don't attempt to put in an IV line! (If your provider asks, say "No thank you!") Administer IM through the clothing. No alcohol swab needed. Team approach to hold down patient for patient and staff safety. Now Listen to the Episode... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 66(3). doi:10.1016/j.annemergmed.2015.03.004 https://www.ncbi.nlm.nih.gov/pubmed/25817884 Lee, E. N., & Lee, J. H. (2016, October 27). The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis.  https://www.ncbi.nlm.nih.gov/pubmed/27788221 Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – 7.  PMID: 28283340 Ketamine: How to Use it Fearlessly For All its Indications by Reuben Strayer. (2015, December 06). https://www.smacc.net.au/2015/12/ketamine-how-to-use-it-fearlessly-for-all-its-indications-by-reuben-strayer/ Strayer, R. (n.d.).

Reuben Strayer, MD Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure     Ready to continue your Special K Trip? Today's episode is Part 2 out of a 3-part series and will cover the use of ketamine for procedural sedation and intubations in the ED with Reuben Strayer, MD. If you didn't listen to Reuben talk about ketamine, the safety measures of ketamine, or confused by this graphic with different dosing - go back and listen to Episode 7 for Part 1 where this is explained in detail.   Ketamine for Procedural Sedation and Analgesia (PSA) Prep Your Patient Therapeutic Communication - let your patient have whatever fantasy they want and encourage it! Any fantasy can be a reality with ketamine...seriously. If they are in so much pain that they are already freaking out and you're not doing your procedure you can give opioids to help calm them down - but remember, ketamine is a powerful analgesia as well...you can always keep them dissociative for a longer duration of time. Situation dependent. Administer your ketamine dosage diluted in Normal Saline and give it slow...best method to prevent psychiatric disturbance. Prep Yourself Place patient on continuous telemonitoring and pulse oximetry Bonus points: CO2 monitoring Airway capable Doctor Watch respirations and breathing closely May have periods of apnea Prevent apnea by administering ketamine slowly (approx. 2 minutes diluted or diluted in Normal Saline 50/100mL over a longer period of time) Expect apnea if you administer ketamine as a fast IV push bolus (1-2 seconds) Patient may still have apnea - MD must know maneuvers to open airway (head position, jaw thrust, BVM, intubation) Nasal Cannula on patient - turn on oxygen as needed I like to have everything connected even if the oxygen is turned off NRM on standby Airway Cart, BVM, and Intubation Kit on standby Suction on standby Nurse who is dedicated to monitor sedation - lots of paperwork and frequent monitoring including watching those respirations! Consent PSA Ketamine Dose Reuben gives a dissociative dose (Ketamine 1-1.5mg/kg). You can get away with giving an analgesic dose but if a patient comes in with a bad fracture - give the dissociative dose and have propofol on hand to counter ketamine's side effects. Ketamine can be used as monotherapy for PSA. Propofol - to counter ketamine's effects (HTN, muscle rigidity, psychiatric emergence, etc.) Draw up in separate syringe. Administer in 20/30/40mg IV pushes as needed Ketofol - Effective but you are not dosing propofol separately. What is it? Ketamine and propofol drawn up in single syringe and administered at the same time. Always Treat Psychiatric Disturbance As your patient metabolizes the ketamine, your patient may "freak out" or have a psychiatric emergence and you must always treat it. It's inhumane to not ignore it and let the patient "ride it out." Use conventional medications to treat: propofol, midazolam, haloperidol, droperidol (if you can get your hands on it) Post PSA Ketamine Pearls NPO until fully alert. Don't stimulate patient prematurely. Minimal noise and minimal physical contact. Nurse with patient entire time monitoring patient until fully alert. Ketamine for Rapid Sequence Intubation (RSI) Okay to use for polytrauma or head trauma (ICP) patients. Has neuroprotective properties - good for ICP/head trauma patients. Induction agent independent from paralytic - doesn't matter if you use rocuronium or succinylcholine - but we are fans of rocuronium for RSIs in the ED. Roc Rocks vs. Sux Sucks -LITFL Extra Ketamine in your syringe? Can use like a push dose pressor while setting up post intubation drips.

Courtesy of Reuben Strayer, MD Reuben Strayer, MD Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure       Back in 2015, Reuben gave an amazing talk on the subject of ketamine and its uses in Emergency Medicine at the SMACC Chicago conference.  It has a lot of fun slides too! I recommend listening to Reuben's SMACC talk first, and then listen to this podcast episode and refer to the show notes. This talk got pretty in depth and long so I broke it up into 3 separate episodes. Today's episode is Part 1, an Introduction to Ketamine.  Part 2 and 3 will cover the applications of Ketamine in the ED in detail. Ketamine Ketamine is traditionally used as an anesthetic in the operating rooms. However, in many ED units, it's commonly used as a procedural sedation agent and an induction agent for intubation. We will be talking about off-label uses including low dose ketamine for analgesia. Take note, you should know your institution's policies. If you don't have one, maybe you can develop some! Safety Alert Must know how to monitor patients who receive ketamine for periods of apnea, psychomimetic disturbances, hypertension, tachycardia. Must have an airway capable provider at the bedside who can quickly intubate if necessary Weight based dosing on all patients. Keep 1 concentration of Ketamine in your ED 2 different concentrations: 100mg/mL and 50mg/mL I like the 50mg/mL concentration and prefer the single-use vials It's easier to push ketamine slower with the weaker concentration.  Otherwise, you can dilute the ketamine. Drawing up ketamine is easier when you want smaller analgesic doses. Also used as a recreational drug (street drug) a.k.a. Special K (not the breakfast cereal), Kit Kat, K, Vitamin C, Cat Valium Major Unwanted Side Effect - Psychomimetic Disturbances or Psychiatric Distress or "K-Hole" (slang) or in other words, they "freak out!" "K-hole" Wikipedia definition: a slang term for the subjective state of dissociation from the body commonly experienced after sufficiently high doses of the dissociative anesthetic ketamine. "K-hole" Urban Dictionary definition (my personal preference): To have used too much of the drug ketamine (special K) and lost sense of time and space, balance, verbal skills. My definition: They are high or stoned out of their mind. Patients can have a good high or a bad high. You'll know the difference right away. You have the power to create a good or bad high. How to mitigate unwanted psychomimetic disturbances? Therapeutic Communication Administer the medication extremely slowly. More evidence is showing that the best way is to dilute your dose into a NS 50mL saline bag (please label it!) and hang it so it's infused in 15 minutes. If you do a traditional bolus push, 3-5 minutes is needed to mitigate psychomimetic disturbances. Give more ketamine to get your patient dissociated. Give propofol to counter ketamine's effects. Give midazalam as another option. Overdosing on ketamine Just prolongs the duration of dissociated state in patient. Look at the Ketamine Brain Continuum slide, the ketamine dosing curve plateaus after the dissociated dose has been reached. Remember, ketamine is weight-based dosing, dosages shown in the slide are for your average adult size. Now listen to the show... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.

Ryan Stanton, MD, FACEP talks to Reuben Strayer, MD on dealing with agitated patients in the ED and strategies to implement best practice for patient care in these difficult situations. www.acep.org

In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

A play by play video of a scalpel finger bougie cric.    As much as I'd like to take credit, original video was filmed by Reuben Strayer with patients consent.    Simply mind blowing how much cognitive work goes into a surgical airway and the video is just an amazing example. Another good example can be found here by Dr Rhee which shows a more traditional surgical approach although a prefer the scalpel finger bougie similar to Scott Wiengart, although I've had favourable experiences with the lifestat recently (seperate episode) . Other References:  The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel–finger–tube' method  

Agitation poses a direct threat to the safety of both patient and staff, as well as being an important manifestation of dangerous conditions that require rapid identification and treatment. Management of agitation consists primarily of physical and chemical restraint, and the details of how restraint is carried out–usually based more on tradition than considered plans or thoughtful protocols–directly determine case outcome. In this talk, we’ll discuss the initial approach to agitation, focusing on the appropriate role of physical restraint, as well as best practice technique for physical restraint. We will then deliberate the options for chemical sedation and propose a menu of the safest and most effective agents for a variety of common agitation scenarios. Some of the questions we will address include: What are the most important dangerous conditions that cause–or are caused by–agitation? What are dangerous restraint holds, and how can physical restraint be accomplished in the safest manner? In the initial management of an agitated patient, should chemical restraint be administered by the intravenous or intramuscular route? How do haloperidol and droperidol compare speed in efficacy when used for calming the agitated patient? How should providers manage concerns around prolonging the QT interval when using butyrophenones for sedation? Which benzodiazepine is preferred, as a treatment for agitation? How should neuroleptics and benzodiazepines be used as monotherapy or in combination? In which type of patient should ketamine be used as a sedation agent? How should ketamine be dosed for tranquilization, and what adverse effects should providers be mindful of when using ketamine for this indication? Can ketamine be used in patients with hyperdynamic vital signs? What is the role of crystalloids in managing the agitated patient? Once the agitated patient has been calmed, what are the primary, secondary and tertiary resuscitative maneuvers (diagnostics and therapeutic)?

Agitation poses a direct threat to the safety of both patient and staff, as well as being an important manifestation of dangerous conditions that require rapid identification and treatment. Management of agitation consists primarily of physical and chemical restraint, and the details of how restraint is carried out–usually based more on tradition than considered plans or thoughtful protocols–directly determine case outcome. In this talk, we’ll discuss the initial approach to agitation, focusing on the appropriate role of physical restraint, as well as best practice technique for physical restraint. We will then deliberate the options for chemical sedation and propose a menu of the safest and most effective agents for a variety of common agitation scenarios. Some of the questions we will address include: What are the most important dangerous conditions that cause–or are caused by–agitation? What are dangerous restraint holds, and how can physical restraint be accomplished in the safest manner? In the initial management of an agitated patient, should chemical restraint be administered by the intravenous or intramuscular route? How do haloperidol and droperidol compare speed in efficacy when used for calming the agitated patient? How should providers manage concerns around prolonging the QT interval when using butyrophenones for sedation? Which benzodiazepine is preferred, as a treatment for agitation? How should neuroleptics and benzodiazepines be used as monotherapy or in combination? In which type of patient should ketamine be used as a sedation agent? How should ketamine be dosed for tranquilization, and what adverse effects should providers be mindful of when using ketamine for this indication? Can ketamine be used in patients with hyperdynamic vital signs? What is the role of crystalloids in managing the agitated patient? Once the agitated patient has been calmed, what are the primary, secondary and tertiary resuscitative maneuvers (diagnostics and therapeutic)?

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_56_0_Final_Cut.m4a Download 3 Comments Tags: Agitation, Droperidol, Excited Delirium, Haloperidol, Lorazepam, Midazolam Show Notes

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_56_0_Final_Cut.m4a Download 3 Comments Tags: Agitation, Droperidol, Excited Delirium, Haloperidol, Lorazepam, Midazolam Show Notes

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_56_0_Final_Cut.m4a Download 3 Comments Tags: Agitation, Droperidol, Excited Delirium, Haloperidol, Lorazepam, Midazolam Show Notes

Reuben Strayer takes us through the myriad uses of Ketamine, and dispells some myths in the process. A Special K classic.

Opiate misuse is everywhere. Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opiates, which now kill more people than heroin and cocaine combined. Opiates are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opiate-related. Four out of 5 new heroin users report that their initial drug was a prescription opiate. In Ontario, three times the people died from opiate overdose than from HIV in 2011. Yet, we are expected to treat pain aggressively in the ED. Dr. Reuben Strayer, the brains behind the fantastic blog EM Updates tells his Best Case Ever, in which he realizes the importance of physician compassion in approaching the challenging drug seekers and malingerers that we manage in the ED on a regular basis. This Best Case Ever is in anticipation of an upcoming main episode in which Dr. Strayer and toxicologist Dr. David Juurlink discuss how to strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction, and how we best take care of our patients who we suspect might have a drug misuse problem. The post Best Case Ever 41 Opiate Misuse and Physician Compassion appeared first on Emergency Medicine Cases.

Opiate misuse is everywhere. Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opiates, which now kill more people than heroin and cocaine combined. Opiates are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opiate-related. Four out of 5 new heroin users report that their initial drug was a prescription opiate. In Ontario, three times the people died from opiate overdose than from HIV in 2011. Yet, we are expected to treat pain aggressively in the ED. Dr. Reuben Strayer, the brains behind the fantastic blog EM Updates tells his Best Case Ever, in which he realizes the importance of physician compassion in approaching the challenging drug seekers and malingerers that we manage in the ED on a regular basis. This Best Case Ever is in anticipation of an upcoming main episode in which Dr. Strayer and toxicologist Dr. David Juurlink discuss how to strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction, and how we best take care of our patients who we suspect might have a drug misuse problem. The post Best Case Ever 41 Opiate Misuse and Physician Compassion appeared first on Emergency Medicine Cases.

Pearls and take home points from our challenging airway workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_6_Finial.m4a Download Leave a Comment Tags: Airway, Challenging Airway, DSI Show Notes Highlighted Resources EMCrit: Podcast 40 – Delayed Sequence Intubation (DSI) EMCrit Wee: Mind Blowing Cricothrotomy Video EP Monthly: NO DESAT! EMCrit: Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer EMUpdates: Optimize the Head During Laryngoscopy Read More

Pearls and take home points from our challenging airway workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_6_Finial.m4a Download Leave a Comment Tags: Airway, Challenging Airway, DSI Show Notes Highlighted Resources EMCrit: Podcast 40 – Delayed Sequence Intubation (DSI) EMCrit Wee: Mind Blowing Cricothrotomy Video EP Monthly: NO DESAT! EMCrit: Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer EMUpdates: Optimize the Head During Laryngoscopy Read More

Pearls and take home points from our challenging airway workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_6_Finial.m4a Download Leave a Comment Tags: Airway, Challenging Airway, DSI Show Notes Highlighted Resources EMCrit: Podcast 40 – Delayed Sequence Intubation (DSI) EMCrit Wee: Mind Blowing Cricothrotomy Video EP Monthly: NO DESAT! EMCrit: Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer EMUpdates: Optimize the Head During Laryngoscopy Read More

Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_4_0_Final_Version.m4a Download Leave a Comment Tags: Airway, Perimortem C-section, Procedural Sedation, RSI Show Notes Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes   Read More

Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_4_0_Final_Version.m4a Download Leave a Comment Tags: Airway, Perimortem C-section, Procedural Sedation, RSI Show Notes Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes   Read More

Episode 4.0 features pearls on perimortem C-sections, procedural sedation and an interview with Reuben Strayer on Airway Nightmares https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_4_0_Final_Version.m4a Download Leave a Comment Tags: Airway, Perimortem C-section, Procedural Sedation, RSI Show Notes Perimortem C-Section Links EMCrit: Perimortem C-Section Procedural Sedation Links EM Updates: Emergency Department Procedural Sedation Checklist V2 EM Updates: The Procedural Sedation Screencast Trilogy EMCrit: Procedural Sedation Resources Airway Nightmares EM Updates: Direct vs. Video Laryngoscopy in 10 Minutes   Read More

FOAMcast is bringing you pearls from conferences we attend including SMACC.   The overarching theme to Day 1 at SMACC?  Use your team-to check you and for feedback.  Dr. Cliff Reid reminded us to follow up our patients and outcomes and learn from it all, without letting our egos get in the way.   Dr. Simon Carley (St. Emlyn's) gave a powerful talk on learning from mistakes later in the day; you will definitely want to listen to these when they come out. We cover trauma pearls from Dr. Scott Weingart, pain pearls from Dr. Reuben Strayer, tox pearls form Dr. David Juurlin, and a bunch of sepsis goodness. 

Hola a todos. Estamos acá en el 2 Congreso de Urgencias (SOCHIMU-SOCHIPRED), dentro del Congreso de la S. Chilena de Medicina Intensiva. Para todos los que no pudieron viajar a la IV Región les cuento que subiré algunas de las presentaciones. En esta oportunidad, subiré las del invitado internacional, el Dr. Reuben Strayer, emergenciólogo de […] The post XXX Congreso de SOCHIMI appeared first on MDU Chile.

Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well.